hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|NE,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Jennie Edmundson Memorial Hospital,2025-09-14,2.0.0,Methodist Jennie Edmundson Hospital,"933 East Pierce Street, Council Bluffs, IA 51503",780039H,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,code|5,code|5|type,modifiers,setting,billing_class,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|min,standard_charge|max,additional_generic_notes,standard_charge|Aetna|Aetna|negotiated_dollar,standard_charge|Aetna|Aetna|negotiated_percentage,standard_charge|Aetna|Aetna|negotiated_algorithm,standard_charge|Aetna|Aetna|methodology,estimated_amount|Aetna|Aetna,additional_payer_notes|Aetna|Aetna,standard_charge|Aetna|Aetna Medicare Advantage|negotiated_dollar,standard_charge|Aetna|Aetna Medicare Advantage|negotiated_percentage,standard_charge|Aetna|Aetna Medicare Advantage|negotiated_algorithm,standard_charge|Aetna|Aetna Medicare Advantage|methodology,estimated_amount|Aetna|Aetna Medicare Advantage,additional_payer_notes|Aetna|Aetna Medicare Advantage,standard_charge|Aetna NHN|Aetna NHN|negotiated_dollar,standard_charge|Aetna NHN|Aetna NHN|negotiated_percentage,standard_charge|Aetna NHN|Aetna NHN|negotiated_algorithm,standard_charge|Aetna NHN|Aetna NHN|methodology,estimated_amount|Aetna NHN|Aetna NHN,additional_payer_notes|Aetna NHN|Aetna NHN,standard_charge|Alliance NHN|Alliance NHN|negotiated_dollar,standard_charge|Alliance NHN|Alliance NHN|negotiated_percentage,standard_charge|Alliance NHN|Alliance NHN|negotiated_algorithm,standard_charge|Alliance NHN|Alliance NHN|methodology,estimated_amount|Alliance NHN|Alliance NHN,additional_payer_notes|Alliance NHN|Alliance NHN,standard_charge|Ambetter by NE Total Care|Ambetter by NE Total Care|negotiated_dollar,standard_charge|Ambetter by NE Total Care|Ambetter by NE Total Care|negotiated_percentage,standard_charge|Ambetter by NE Total Care|Ambetter by NE Total Care|negotiated_algorithm,standard_charge|Ambetter by NE Total Care|Ambetter by NE Total Care|methodology,estimated_amount|Ambetter by NE Total Care|Ambetter by NE Total Care,additional_payer_notes|Ambetter by NE Total Care|Ambetter by NE Total Care,standard_charge|Amerigroup|Amerigroup IA Medicaid - MJE|negotiated_dollar,standard_charge|Amerigroup|Amerigroup IA Medicaid - MJE|negotiated_percentage,standard_charge|Amerigroup|Amerigroup IA Medicaid - MJE|negotiated_algorithm,standard_charge|Amerigroup|Amerigroup IA Medicaid - MJE|methodology,estimated_amount|Amerigroup|Amerigroup IA Medicaid - MJE,additional_payer_notes|Amerigroup|Amerigroup IA Medicaid - MJE,standard_charge|Amerivantage Medicare Advantage|Amerivantage Medicare Advantage by Amerigroup|negotiated_dollar,standard_charge|Amerivantage Medicare Advantage|Amerivantage Medicare Advantage by Amerigroup|negotiated_percentage,standard_charge|Amerivantage Medicare Advantage|Amerivantage Medicare Advantage by Amerigroup|negotiated_algorithm,standard_charge|Amerivantage Medicare Advantage|Amerivantage Medicare Advantage by Amerigroup|methodology,estimated_amount|Amerivantage Medicare Advantage|Amerivantage Medicare Advantage by Amerigroup,additional_payer_notes|Amerivantage Medicare Advantage|Amerivantage Medicare Advantage by Amerigroup,standard_charge|AMPS|AMPS|negotiated_dollar,standard_charge|AMPS|AMPS|negotiated_percentage,standard_charge|AMPS|AMPS|negotiated_algorithm,standard_charge|AMPS|AMPS|methodology,estimated_amount|AMPS|AMPS,additional_payer_notes|AMPS|AMPS,standard_charge|BCBS|BCBS|negotiated_dollar,standard_charge|BCBS|BCBS|negotiated_percentage,standard_charge|BCBS|BCBS|negotiated_algorithm,standard_charge|BCBS|BCBS|methodology,estimated_amount|BCBS|BCBS,additional_payer_notes|BCBS|BCBS,standard_charge|BCBS|BCBS Medicare Advantage|negotiated_dollar,standard_charge|BCBS|BCBS Medicare Advantage|negotiated_percentage,standard_charge|BCBS|BCBS Medicare Advantage|negotiated_algorithm,standard_charge|BCBS|BCBS Medicare Advantage|methodology,estimated_amount|BCBS|BCBS Medicare Advantage,additional_payer_notes|BCBS|BCBS Medicare Advantage,standard_charge|BCBS|BCBS Select|negotiated_dollar,standard_charge|BCBS|BCBS Select|negotiated_percentage,standard_charge|BCBS|BCBS Select|negotiated_algorithm,standard_charge|BCBS|BCBS Select|methodology,estimated_amount|BCBS|BCBS Select,additional_payer_notes|BCBS|BCBS Select,standard_charge|Medica|Elevate by Medica|negotiated_dollar,standard_charge|Medica|Elevate by Medica|negotiated_percentage,standard_charge|Medica|Elevate by Medica|negotiated_algorithm,standard_charge|Medica|Elevate by Medica|methodology,estimated_amount|Medica|Elevate by Medica,additional_payer_notes|Medica|Elevate by Medica,standard_charge|Elite Choice - MJE|Elite Choice - MJE|negotiated_dollar,standard_charge|Elite Choice - MJE|Elite Choice - MJE|negotiated_percentage,standard_charge|Elite Choice - MJE|Elite Choice - MJE|negotiated_algorithm,standard_charge|Elite Choice - MJE|Elite Choice - MJE|methodology,estimated_amount|Elite Choice - MJE|Elite Choice - MJE,additional_payer_notes|Elite Choice - MJE|Elite Choice - MJE,standard_charge|First Health|First Health|negotiated_dollar,standard_charge|First Health|First Health|negotiated_percentage,standard_charge|First Health|First Health|negotiated_algorithm,standard_charge|First Health|First Health|methodology,estimated_amount|First Health|First Health,additional_payer_notes|First Health|First Health,standard_charge|Humana|Humana Medicare Advantage|negotiated_dollar,standard_charge|Humana|Humana Medicare Advantage|negotiated_percentage,standard_charge|Humana|Humana Medicare Advantage|negotiated_algorithm,standard_charge|Humana|Humana Medicare Advantage|methodology,estimated_amount|Humana|Humana Medicare Advantage,additional_payer_notes|Humana|Humana Medicare Advantage,standard_charge|IA Total Care|IA Total Care - MJE|negotiated_dollar,standard_charge|IA Total Care|IA Total Care - MJE|negotiated_percentage,standard_charge|IA Total Care|IA Total Care - MJE|negotiated_algorithm,standard_charge|IA Total Care|IA Total Care - MJE|methodology,estimated_amount|IA Total Care|IA Total Care - MJE,additional_payer_notes|IA Total Care|IA Total Care - MJE,standard_charge|Immanuel Pathways PACE|Immanuel Pathways PACE - MJE|negotiated_dollar,standard_charge|Immanuel Pathways PACE|Immanuel Pathways PACE - MJE|negotiated_percentage,standard_charge|Immanuel Pathways PACE|Immanuel Pathways PACE - MJE|negotiated_algorithm,standard_charge|Immanuel Pathways PACE|Immanuel Pathways PACE - MJE|methodology,estimated_amount|Immanuel Pathways PACE|Immanuel Pathways PACE - MJE,additional_payer_notes|Immanuel Pathways PACE|Immanuel Pathways PACE - MJE,standard_charge|Medica Choice|Medica Choice|negotiated_dollar,standard_charge|Medica Choice|Medica Choice|negotiated_percentage,standard_charge|Medica Choice|Medica Choice|negotiated_algorithm,standard_charge|Medica Choice|Medica Choice|methodology,estimated_amount|Medica Choice|Medica Choice,additional_payer_notes|Medica Choice|Medica Choice,standard_charge|Medica|Medica Medicare Advantage|negotiated_dollar,standard_charge|Medica|Medica Medicare Advantage|negotiated_percentage,standard_charge|Medica|Medica Medicare Advantage|negotiated_algorithm,standard_charge|Medica|Medica Medicare Advantage|methodology,estimated_amount|Medica|Medica Medicare Advantage,additional_payer_notes|Medica|Medica Medicare Advantage,standard_charge|Midlands Choice|Midlands Choice - MJE|negotiated_dollar,standard_charge|Midlands Choice|Midlands Choice - MJE|negotiated_percentage,standard_charge|Midlands Choice|Midlands Choice - MJE|negotiated_algorithm,standard_charge|Midlands Choice|Midlands Choice - MJE|methodology,estimated_amount|Midlands Choice|Midlands Choice - MJE,additional_payer_notes|Midlands Choice|Midlands Choice - MJE,standard_charge|Molina IA Medicaid MCO|Molina IA Medicaid MCO - MJE|negotiated_dollar,standard_charge|Molina IA Medicaid MCO|Molina IA Medicaid MCO - MJE|negotiated_percentage,standard_charge|Molina IA Medicaid MCO|Molina IA Medicaid MCO - MJE|negotiated_algorithm,standard_charge|Molina IA Medicaid MCO|Molina IA Medicaid MCO - MJE|methodology,estimated_amount|Molina IA Medicaid MCO|Molina IA Medicaid MCO - MJE,additional_payer_notes|Molina IA Medicaid MCO|Molina IA Medicaid MCO - MJE,standard_charge|Molina Medicare Advantage|Molina Medicare Advantage|negotiated_dollar,standard_charge|Molina Medicare Advantage|Molina Medicare Advantage|negotiated_percentage,standard_charge|Molina Medicare Advantage|Molina Medicare Advantage|negotiated_algorithm,standard_charge|Molina Medicare Advantage|Molina Medicare Advantage|methodology,estimated_amount|Molina Medicare Advantage|Molina Medicare Advantage,additional_payer_notes|Molina Medicare Advantage|Molina Medicare Advantage,standard_charge|Molina NE Medicaid|Molina NE Medicaid - MJE|negotiated_dollar,standard_charge|Molina NE Medicaid|Molina NE Medicaid - MJE|negotiated_percentage,standard_charge|Molina NE Medicaid|Molina NE Medicaid - MJE|negotiated_algorithm,standard_charge|Molina NE Medicaid|Molina NE Medicaid - MJE|methodology,estimated_amount|Molina NE Medicaid|Molina NE Medicaid - MJE,additional_payer_notes|Molina NE Medicaid|Molina NE Medicaid - MJE,standard_charge|Multiplan|Multiplan|negotiated_dollar,standard_charge|Multiplan|Multiplan|negotiated_percentage,standard_charge|Multiplan|Multiplan|negotiated_algorithm,standard_charge|Multiplan|Multiplan|methodology,estimated_amount|Multiplan|Multiplan,additional_payer_notes|Multiplan|Multiplan,standard_charge|NE Furniture Mart|NE Furniture Mart|negotiated_dollar,standard_charge|NE Furniture Mart|NE Furniture Mart|negotiated_percentage,standard_charge|NE Furniture Mart|NE Furniture Mart|negotiated_algorithm,standard_charge|NE Furniture Mart|NE Furniture Mart|methodology,estimated_amount|NE Furniture Mart|NE Furniture Mart,additional_payer_notes|NE Furniture Mart|NE Furniture Mart,standard_charge|NE Total Care|NE Total Care NE Medicaid MCO - MJE|negotiated_dollar,standard_charge|NE Total Care|NE Total Care NE Medicaid MCO - MJE|negotiated_percentage,standard_charge|NE Total Care|NE Total Care NE Medicaid MCO - MJE|negotiated_algorithm,standard_charge|NE Total Care|NE Total Care NE Medicaid MCO - MJE|methodology,estimated_amount|NE Total Care|NE Total Care NE Medicaid MCO - MJE,additional_payer_notes|NE Total Care|NE Total Care NE Medicaid MCO - MJE,standard_charge|United Healthcare|UHC|negotiated_dollar,standard_charge|United Healthcare|UHC|negotiated_percentage,standard_charge|United Healthcare|UHC|negotiated_algorithm,standard_charge|United Healthcare|UHC|methodology,estimated_amount|United Healthcare|UHC,additional_payer_notes|United Healthcare|UHC,standard_charge|United Healthcare|UHC Medicare Advantage|negotiated_dollar,standard_charge|United Healthcare|UHC Medicare Advantage|negotiated_percentage,standard_charge|United Healthcare|UHC Medicare Advantage|negotiated_algorithm,standard_charge|United Healthcare|UHC Medicare Advantage|methodology,estimated_amount|United Healthcare|UHC Medicare Advantage,additional_payer_notes|United Healthcare|UHC Medicare Advantage,standard_charge|United Healthcare|UHC NE Medicaid - MJE|negotiated_dollar,standard_charge|United Healthcare|UHC NE Medicaid - MJE|negotiated_percentage,standard_charge|United Healthcare|UHC NE Medicaid - MJE|negotiated_algorithm,standard_charge|United Healthcare|UHC NE Medicaid - MJE|methodology,estimated_amount|United Healthcare|UHC NE Medicaid - MJE,additional_payer_notes|United Healthcare|UHC NE Medicaid - MJE,standard_charge|UHC|UHC NEXUS|negotiated_dollar,standard_charge|UHC|UHC NEXUS|negotiated_percentage,standard_charge|UHC|UHC NEXUS|negotiated_algorithm,standard_charge|UHC|UHC NEXUS|methodology,estimated_amount|UHC|UHC NEXUS,additional_payer_notes|UHC|UHC NEXUS,standard_charge|Wellcare Medicare Advantage|Wellcare Medicare Advantage by NE Total Care|negotiated_dollar,standard_charge|Wellcare Medicare Advantage|Wellcare Medicare Advantage by NE Total Care|negotiated_percentage,standard_charge|Wellcare Medicare Advantage|Wellcare Medicare Advantage by NE Total Care|negotiated_algorithm,standard_charge|Wellcare Medicare Advantage|Wellcare Medicare Advantage by NE Total Care|methodology,estimated_amount|Wellcare Medicare Advantage|Wellcare Medicare Advantage by NE Total Care,additional_payer_notes|Wellcare Medicare Advantage|Wellcare Medicare Advantage by NE Total Care,standard_charge|Wellmark|Wellmark HMO - MJE|negotiated_dollar,standard_charge|Wellmark|Wellmark HMO - MJE|negotiated_percentage,standard_charge|Wellmark|Wellmark HMO - MJE|negotiated_algorithm,standard_charge|Wellmark|Wellmark HMO - MJE|methodology,estimated_amount|Wellmark|Wellmark HMO - MJE,additional_payer_notes|Wellmark|Wellmark HMO - MJE,standard_charge|Wellmark Medicare Advantage|Wellmark Medicare Advantage|negotiated_dollar,standard_charge|Wellmark Medicare Advantage|Wellmark Medicare Advantage|negotiated_percentage,standard_charge|Wellmark Medicare Advantage|Wellmark Medicare Advantage|negotiated_algorithm,standard_charge|Wellmark Medicare Advantage|Wellmark Medicare Advantage|methodology,estimated_amount|Wellmark Medicare Advantage|Wellmark Medicare Advantage,additional_payer_notes|Wellmark Medicare Advantage|Wellmark Medicare Advantage,standard_charge|Wellmark|Wellmark PPO - MJE|negotiated_dollar,standard_charge|Wellmark|Wellmark PPO - MJE|negotiated_percentage,standard_charge|Wellmark|Wellmark PPO - MJE|negotiated_algorithm,standard_charge|Wellmark|Wellmark PPO - MJE|methodology,estimated_amount|Wellmark|Wellmark PPO - MJE,additional_payer_notes|Wellmark|Wellmark PPO - MJE
Electrolytes,1,CDM,0300,RC,80051,CPT,,,,,,outpatient,facility,,,84.00,25.20,6.66,71.40,,29.82,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.87,,,fee schedule,,,22.25,,,fee schedule,,,14.62,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,14.51,,,fee schedule,,,6.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.01,,,fee schedule,,,15.84,,,fee schedule,,,,,,,,,6.87,,,fee schedule,,,,,,,,,8.85,,,fee schedule,,,14.30,,,fee schedule,,,63.0,,,percent of total billed charges,,,6.87,,,fee schedule,,,6.66,,,fee schedule,,,7.01,,,fee schedule,,,10.41,,,fee schedule,,,6.87,,,fee schedule,,,63.0,,,percent of total billed charges,,,,,,,,,7.01,,,fee schedule,,,,,,,,,71.40,,,percent of total billed charges,,,38.64,,,percent of total billed charges,,,,,,,,,7.71,,,fee schedule,,,6.87,,,fee schedule,,,,,,,,,6.80,,,fee schedule,,,6.87,,,fee schedule,,,,,,,,,6.94,,,fee schedule,,,,,,,,
Electrolytes,1,CDM,0300,RC,80051,CPT,403,EAPG,,,,outpatient,facility,,,84.00,25.20,10.64,51.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,28.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,47.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,51.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH TREK RE 2.25X06MM,10001104,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK RE 3.25X12MM,10001105,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4X28MM X_7382-5228 X_SMITH NEPHEW,10001106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,154.00,46.20,59.75,130.90,,,,,,,,,,,,,,,,,,,,59.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,,69.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4X28MM X_7382-5228 X_SMITH NEPHEW,10001106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,154.00,46.20,65.45,130.90,,,,,,,,,,,,,service not payable,,,,,,,77.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,70.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE ALTITUDE T2 13MM 19-23 X_9391319 X_MEDTRONIC,10001107,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,23768.00,7130.40,9221.98,20202.80,,11646.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9982.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9221.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10101.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17826.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11884.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20202.80,,,percent of total billed charges,,,10695.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE ALTITUDE T2 13MM 19-23 X_9391319 X_MEDTRONIC,10001107,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,23768.00,7130.40,9982.56,20202.80,,11646.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9982.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11988.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10101.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17826.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11884.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17826.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,20202.80,,,percent of total billed charges,,,10933.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TI THREADED BONE,10001108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TI THREADED BONE,10001108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DOME INFINITY TALAR SZ2 X_33630022 X_WRIGHT MEDICA,10001109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,19483.00,5844.90,7559.40,16560.55,,9546.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8182.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7559.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8280.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14612.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9741.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16560.55,,,percent of total billed charges,,,8767.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOME INFINITY TALAR SZ2 X_33630022 X_WRIGHT MEDICA,10001109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,19483.00,5844.90,8182.86,16560.55,,9546.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8182.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9827.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8280.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14612.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9741.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14612.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16560.55,,,percent of total billed charges,,,8962.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT INFINITY POLY SZ2 8MM X_33653208 X_WRIGHT M,10001110,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT INFINITY POLY SZ2 8MM X_33653208 X_WRIGHT M,10001110,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 4MM 7CM,10001114,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 5MM 11CM,10001115,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 6MM 9CM X_45-750609 X_TERUMO MED,10001116,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 6MM 17CM,10001117,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 8MM 12CM,10001118,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 8MM 24CM,10001119,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 16MM 32CM,10001120,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 20MM 39CM,10001121,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 10.5,10001122,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 10.5,10001122,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 10.0,10001123,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 10.0,10001123,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 27.0,10001124,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 27.0,10001124,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 28.5,10001125,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 28.5,10001125,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 29.0,10001126,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 29.0,10001126,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 29.5,10001127,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 29.5,10001127,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 10.5,10001128,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 10.5,10001128,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 13.5,10001129,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 13.5,10001129,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 26.5,10001130,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 26.5,10001130,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 27.0,10001131,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 27.0,10001131,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIX ACRYLIC 27.5 X_ZA9003-27.5 X_PRECISION,10001132,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIX ACRYLIC 27.5 X_ZA9003-27.5 X_PRECISION,10001132,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 28.5,10001133,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 28.5,10001133,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIX ACRYLIC 29.5 X_ZA9003-29.5 X_PRECISION,10001134,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIX ACRYLIC 29.5 X_ZA9003-29.5 X_PRECISION,10001134,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 30.0,10001135,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,873.00,261.90,338.72,742.05,,,,,,,,,,,,,,,,,,,,338.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.05,,,percent of total billed charges,,,392.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 30.0,10001135,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,,,,,,,,,,,,service not payable,,,,,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK FRACTURE 6H 43MM,10001136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK FRACTURE 6H 43MM,10001136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOLOGIC CELL BONE MTRX 10CC X_BIO4 X_STRYKER ORTH,10003096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,17834.00,5350.20,6919.59,15158.9,,8738.66,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7490.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6919.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7579.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13375.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8917.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15158.9,,,percent of total billed charges,,,8025.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOLOGIC CELL BONE MTRX 10CC X_BIO4 X_STRYKER ORTH,10003096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,17834.00,5350.20,7490.28,15158.9,,8738.66,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7490.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8995.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7579.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13375.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8917.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13375.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15158.9,,,percent of total billed charges,,,8203.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DBL BAR 6H 3X4X5MM,10003098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1343.00,402.90,521.08,1141.55,,,,,,,,,,,,,,,,,,,,521.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1007.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.55,,,percent of total billed charges,,,604.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DBL BAR 6H 3X4X5MM,10003098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1343.00,402.90,570.77,1141.55,,,,,,,,,,,,,service not payable,,,,,,,677.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1007.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1007.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1141.55,,,percent of total billed charges,,,617.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD EVOLVE COCR 20MM X_496-H220 X_WRIGHT MEDICAL,10003101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5877.00,1763.10,2280.28,4995.45,,2879.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2468.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2280.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2497.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4407.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2938.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4995.45,,,percent of total billed charges,,,2644.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD EVOLVE COCR 20MM X_496-H220 X_WRIGHT MEDICAL,10003101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5877.00,1763.10,2468.34,4995.45,,2879.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2468.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2964.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2497.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4407.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2938.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4407.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4995.45,,,percent of total billed charges,,,2703.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP ST HDLS 7X45MM X_658345 X_STRYKER,10003102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP ST HDLS 7X45MM X_658345 X_STRYKER,10003102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP ST HDLS 7X60MM X_658360 X_STRYKER,10003103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP ST HDLS 7X60MM X_658360 X_STRYKER,10003103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE KIRSCHNER COMP 3.2X230MM,10003105,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,591.00,177.30,251.18,502.35,,365.24,,,percent of total billed charges,,,,,,,,service not payable,288.41,,,percent of total billed charges,,,298.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,251.18,,,percent of total billed charges,,,,,,,,,443.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,443.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,502.35,,,percent of total billed charges,,,271.86,,,percent of total billed charges,,,,,,,,,384.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,384.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VIABLE MATRIX 10CC,10003106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,17834.00,5350.20,6919.59,15158.9,,8738.66,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7490.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6919.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7579.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13375.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8917.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15158.9,,,percent of total billed charges,,,8025.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VIABLE MATRIX 10CC,10003106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,17834.00,5350.20,7490.28,15158.9,,8738.66,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7490.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8995.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7579.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13375.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8917.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13375.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15158.9,,,percent of total billed charges,,,8203.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL PS FB SZ6 16MM X_1516-40-616 X_DEPUY,10007100,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL PS FB SZ6 16MM X_1516-40-616 X_DEPUY,10007100,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT SALVATION 5X110MM X_SB050110 X_WRIGHT MEDICAL,10007103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5827.00,1748.10,2260.88,4952.95,,2855.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2447.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2260.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2476.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4370.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2913.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4952.95,,,percent of total billed charges,,,2622.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT SALVATION 5X110MM X_SB050110 X_WRIGHT MEDICAL,10007103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5827.00,1748.10,2447.34,4952.95,,2855.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2447.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2939.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2476.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4370.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2913.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4370.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4952.95,,,percent of total billed charges,,,2680.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT SALVATION 6.5X120MM X_SB065120 X_WRIGHT MEDIC,10007104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6259.00,1877.70,2428.49,5320.15,,3066.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2628.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2428.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2660.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4694.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3129.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5320.15,,,percent of total billed charges,,,2816.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT SALVATION 6.5X120MM X_SB065120 X_WRIGHT MEDIC,10007104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6259.00,1877.70,2628.78,5320.15,,3066.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2628.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3157.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2660.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4694.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3129.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4694.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5320.15,,,percent of total billed charges,,,2879.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON LCKG 2X7MM X_25-672-07-91 X_KLS MARTIN L,10007105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,226.00,67.80,87.69,192.10,,,,,,,,,,,,,,,,,,,,87.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.10,,,percent of total billed charges,,,101.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LCKG 2X7MM X_25-672-07-91 X_KLS MARTIN L,10007105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,226.00,67.80,96.05,192.10,,,,,,,,,,,,,service not payable,,,,,,,113.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,169.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.10,,,percent of total billed charges,,,103.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 12F 33CM,10007107,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2443.00,732.90,1038.28,2076.55,,1509.77,,,percent of total billed charges,,,,,,,,service not payable,1192.18,,,percent of total billed charges,,,1232.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1038.28,,,percent of total billed charges,,,,,,,,,1832.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1221.5,,,percent of total billed charges,,,,,,,,service not payable,1832.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2076.55,,,percent of total billed charges,,,1123.78,,,percent of total billed charges,,,,,,,,,1587.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1587.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 16F 33CM,10007108,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2382.00,714.60,1012.35,2024.7,,1472.08,,,percent of total billed charges,,,,,,,,service not payable,1162.42,,,percent of total billed charges,,,1201.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1012.35,,,percent of total billed charges,,,,,,,,,1786.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1191.0,,,percent of total billed charges,,,,,,,,service not payable,1786.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2024.7,,,percent of total billed charges,,,1095.72,,,percent of total billed charges,,,,,,,,,1548.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1548.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT IPSL LEG 23X14.5X14CM,10007109,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,36962.00,11088.60,14341.26,31417.70,,18111.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15524.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14341.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15708.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18481.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31417.70,,,percent of total billed charges,,,16632.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT IPSL LEG 23X14.5X14CM,10007109,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,36962.00,11088.60,15524.04,31417.70,,18111.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15524.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18643.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15708.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27721.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18481.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27721.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31417.70,,,percent of total billed charges,,,17002.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDE SURFACE CR DO T2/210MM X_NN220 X_DEPUY,10007110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDE SURFACE CR DO T2/210MM X_NN220 X_DEPUY,10007110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NARROW FEMUR F4NL X_NN899Z X_DEPUY,10007111,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NARROW FEMUR F4NL X_NN899Z X_DEPUY,10007111,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ESSENTIO DUAL DR,10007112,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,6842.00,2052.60,2654.70,5815.70,,3352.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2873.64,,,percent of total billed charges,,Paid in addition to inpatient services ,2654.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2907.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5131.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3421.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5815.70,,,percent of total billed charges,,,3078.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ESSENTIO DUAL DR,10007112,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,6842.00,2052.60,2873.64,5815.70,,3352.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2873.64,,,percent of total billed charges,,Paid in addition to outpatient services ,3451.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2907.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5131.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3421.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5131.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5815.70,,,percent of total billed charges,,,3147.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE INVIZIA ANTERIOR 26MM,10007113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE INVIZIA ANTERIOR 26MM,10007113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Clar K-RAS addl,10009096,CDM,0310,RC,81276,CPT,,,,,,outpatient,facility,,,191.00,57.30,87.86,431.66,,118.04,,,percent of total billed charges,,,187.18,,,fee schedule,,,93.97,,,fee schedule,,,403.03,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,395.37,,,fee schedule,,,183.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",190.92,,,fee schedule,,,431.66,,,fee schedule,,,,,,,,,187.18,,,fee schedule,,,,,,,,,248.56,,,fee schedule,,,389.64,,,fee schedule,,,143.25,,,percent of total billed charges,,,187.18,,,fee schedule,,,183.59,,,fee schedule,,,190.92,,,fee schedule,,,292.31,,,fee schedule,,,187.18,,,fee schedule,,,143.25,,,percent of total billed charges,,,183.59,,,fee schedule,,,190.92,,,fee schedule,,,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,212.58,,,fee schedule,,,187.18,,,fee schedule,,,,,,,,,187.45,,,fee schedule,,,187.18,,,fee schedule,,,,,,,,,187.18,,,fee schedule,,,,,,,,
Clar K-RAS addl,10009096,CDM,0310,RC,81276,CPT,386,EAPG,,,,outpatient,facility,,,191.00,57.30,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Injection diag or therapeutic substance not inclu,10009111,CDM,0761,RC,62320,CPT,,,,,,outpatient,facility,,,2138.00,641.40,118.0,1817.3,,1321.28,,,percent of total billed charges,,,,,,,,,1043.34,,,percent of total billed charges,,,1078.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.65,,,percent of total billed charges,,,,,,,,,1603.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1069.0,,,percent of total billed charges,,,,,,,,,1603.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1817.3,,,percent of total billed charges,,,983.48,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Injection diag or therapeutic substance not inclu,10009111,CDM,0761,RC,62320,CPT,05442,APC,,,,outpatient,facility,,,2138.00,641.40,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Injection diag or therapeutic substance not inclu,10009111,CDM,0761,RC,62320,CPT,53,EAPG,,,,outpatient,facility,,,2138.00,641.40,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT INTERAOCULAR LT 0.33MM,10009120,CDM,0278,RC,C1783,HCPCS,,,,,,inpatient,facility,,,7049.00,2114.70,2735.01,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2735.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5991.65,,,percent of total billed charges,,,3172.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INTERAOCULAR LT 0.33MM,10009120,CDM,0278,RC,C1783,HCPCS,,,,,,outpatient,facility,,,7049.00,2114.70,2960.58,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3555.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5991.65,,,percent of total billed charges,,,3242.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Beta-HCG Quantitative - Tumor Marker,10009127,CDM,0300,RC,84702,CPT,,,,,,outpatient,facility,,,100.00,30.00,14.30,85.0,,63.98,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.75,,,fee schedule,,,47.74,,,fee schedule,,,31.39,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,31.15,,,fee schedule,,,14.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",15.04,,,fee schedule,,,34.01,,,fee schedule,,,,,,,,,14.75,,,fee schedule,,,,,,,,,19.38,,,fee schedule,,,30.70,,,fee schedule,,,75.0,,,percent of total billed charges,,,14.75,,,fee schedule,,,14.30,,,fee schedule,,,15.04,,,fee schedule,,,22.79,,,fee schedule,,,14.75,,,fee schedule,,,75.0,,,percent of total billed charges,,,,,,,,,15.04,,,fee schedule,,,,,,,,,85.0,,,percent of total billed charges,,,46.0,,,percent of total billed charges,,,,,,,,,16.56,,,fee schedule,,,14.75,,,fee schedule,,,,,,,,,14.6,,,fee schedule,,,14.75,,,fee schedule,,,,,,,,,14.9,,,fee schedule,,,,,,,,
Beta-HCG Quantitative - Tumor Marker,10009127,CDM,0300,RC,84702,CPT,398,EAPG,,,,outpatient,facility,,,100.00,30.00,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HEAD FEM BIOLOX UNIV 40MM X_6519-1-040 X_STRYKER O,10011103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX UNIV 40MM X_6519-1-040 X_STRYKER O,10011103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAPTOR SLVE UNIV V40 4 X_6519-T-204 X_STRYKER ORT,10011104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADAPTOR SLVE UNIV V40 4 X_6519-T-204 X_STRYKER ORT,10011104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG CP 3.6X22MM X_626922 X_STRYKER ORTHOPAED,10011106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1161.00,348.30,450.47,986.85,,,,,,,,,,,,,,,,,,,,450.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,870.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,580.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,986.85,,,percent of total billed charges,,,522.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG CP 3.6X22MM X_626922 X_STRYKER ORTHOPAED,10011106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1161.00,348.30,493.43,986.85,,,,,,,,,,,,,service not payable,,,,,,,585.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,493.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,870.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,580.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,870.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,986.85,,,percent of total billed charges,,,534.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.7X10MM,10011107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1208.00,362.40,468.70,1026.8,,,,,,,,,,,,,,,,,,,,468.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1026.8,,,percent of total billed charges,,,543.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.7X10MM,10011107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1208.00,362.40,513.40,1026.8,,,,,,,,,,,,,service not payable,,,,,,,609.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,906.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1026.8,,,percent of total billed charges,,,555.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T10 FT 3.5X26MM,10011108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1361.00,408.30,528.07,1156.85,,,,,,,,,,,,,,,,,,,,528.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.85,,,percent of total billed charges,,,612.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T10 FT 3.5X26MM,10011108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1361.00,408.30,578.42,1156.85,,,,,,,,,,,,,service not payable,,,,,,,686.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.85,,,percent of total billed charges,,,626.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON LCKG 3.5X22MM X_657422 X_STRYKER,10011109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LCKG 3.5X22MM X_657422 X_STRYKER,10011109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG POLYAX MEDI-COL LT SHORT X_626771 X_STR,10011110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6153.00,1845.90,2387.36,5230.05,,3014.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2584.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2387.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2615.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4614.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3076.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5230.05,,,percent of total billed charges,,,2768.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG POLYAX MEDI-COL LT SHORT X_626771 X_STR,10011110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6153.00,1845.90,2584.26,5230.05,,3014.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2584.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3103.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2615.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4614.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3076.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4614.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5230.05,,,percent of total billed charges,,,2830.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR HEALICOIL REGENESORB 5.5MM X_72203801 X_SMI,10011113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR HEALICOIL REGENESORB 5.5MM X_72203801 X_SMI,10011113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX LP 2.4X10MM,10011114,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX LP 2.4X10MM,10011114,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COLLAR CERVICAL 2IN X 23.5 LG,10011115,CDM,0274,RC,L0120,HCPCS,,,,,,inpatient,facility,,,52.00,15.60,20.18,44.20,,,,,,,,,,,,,,,,,,,,20.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,39.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.20,,,percent of total billed charges,,,23.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAR CERVICAL 2IN X 23.5 LG,10011115,CDM,0274,RC,L0120,HCPCS,,,,,,outpatient,facility,,,52.00,15.60,22.10,90.11,,,,,,,,39.23,,,fee schedule,,,,,,,,,26.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,82.53,,,fee schedule,,,27.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",40.01,,,fee schedule,,,90.11,,,fee schedule,,,,,,,,,39.23,,,fee schedule,,,,,,,,,22.10,,,percent of total billed charges,,Paid in addition to outpatient services ,81.33,,,fee schedule,,,39.0,,,percent of total billed charges,,,39.23,,,fee schedule,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,26.0,,,percent of total billed charges,,Paid in addition to outpatient services ,39.23,,,fee schedule,,,39.0,,,percent of total billed charges,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,,,,,,,44.20,,,percent of total billed charges,,,23.92,,,percent of total billed charges,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,39.63,,,fee schedule,,,,,,,,
IMPLANT BRST INSPIRA SCF 180ML X_SCF-180 X_ALLERGA,10011116,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCF 180ML X_SCF-180 X_ALLERGA,10011116,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCF 200ML X_SCF-200 X_ALLERGA,10011117,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCF 200ML X_SCF-200 X_ALLERGA,10011117,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCF 220ML X_SCF-220 X_ALLERGA,10011118,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCF 220ML X_SCF-220 X_ALLERGA,10011118,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 240CC,10011119,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 240CC,10011119,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 265CC,10011120,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 265CC,10011120,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 295CC,10011121,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 295CC,10011121,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 325CC,10011122,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 325CC,10011122,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCF 335ML X_SCF-335 X_ALLERGA,10011123,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCF 335ML X_SCF-335 X_ALLERGA,10011123,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 345CC,10011124,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 345CC,10011124,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 365CC,10011125,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 365CC,10011125,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 385CC,10011126,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 385CC,10011126,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCF 415ML X_SCF-415 X_ALLERGA,10011127,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCF 415ML X_SCF-415 X_ALLERGA,10011127,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 450CC,10011128,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 450CC,10011128,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 485CC,10011129,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 485CC,10011129,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 520CC,10011130,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 520CC,10011130,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 560CC,10011131,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 560CC,10011131,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 605CC,10011132,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 605CC,10011132,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCF 650ML X_SCF-650 X_ALLERGA,10011133,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCF 650ML X_SCF-650 X_ALLERGA,10011133,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 695CC,10011134,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 695CC,10011134,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 745CC,10011135,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 745CC,10011135,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCF 770CC,10011136,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCF 770CC,10011136,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 345ML X_MSZ-F345 X_ALLERGAN,10011145,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 365ML X_MSZ-F365 X_ALLERGAN,10011146,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRF 365ML X_MSZ-F365 X_ALLERGAN,10011146,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 385ML X_MSZ-F385 X_ALLERGAN,10011147,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRF 385ML X_MSZ-F385 X_ALLERGAN,10011147,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 415ML X_MSZ-F415 X_ALLERGAN,10011148,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRF 415ML X_MSZ-F415 X_ALLERGAN,10011148,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 450ML X_MSZ-F450 X_ALLERGAN,10011149,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 485ML X_MSZ-F485 X_ALLERGAN,10011150,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 520ML X_MSZ-F520 X_ALLERGAN,10011151,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRF 520ML X_MSZ-F520 X_ALLERGAN,10011151,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 560ML X_MSZ-F560 X_ALLERGAN,10011152,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRF 605CC,10011153,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ESSENTIO SINGLE DR,10011155,CDM,0275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,6705.00,2011.50,2601.54,5699.25,,3285.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2816.10,,,percent of total billed charges,,Paid in addition to inpatient services ,2601.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2849.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5028.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5699.25,,,percent of total billed charges,,,3017.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ESSENTIO SINGLE DR,10011155,CDM,0275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,6705.00,2011.50,2816.10,5699.25,,3285.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2816.10,,,percent of total billed charges,,Paid in addition to outpatient services ,3382.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2849.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5028.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5028.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5699.25,,,percent of total billed charges,,,3084.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD INNOMED MYOCRD BIPLR 35CM,10011156,CDM,0278,RC,C1898,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD INNOMED MYOCRD BIPLR 35CM,10011156,CDM,0278,RC,C1898,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD INNOMED MYOCRD BIPLR 54CM,10011157,CDM,0278,RC,C1898,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD INNOMED MYOCRD BIPLR 54CM,10011157,CDM,0278,RC,C1898,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK RE 2.75X30MM,10011159,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
US Extremity Non Vascular,10011165,CDM,0402,RC,76882,CPT,,,,,,outpatient,facility,,,738.00,221.40,23.86,627.30,,31.98,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,23.86,,,fee schedule,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,230.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
US Extremity Non Vascular,10011165,CDM,0402,RC,76882,CPT,05522,APC,,,,outpatient,facility,,,738.00,221.40,97.82,234.20,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,214.51,,,fee schedule,,,97.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,211.41,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,97.82,,,fee schedule,,,104.01,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,97.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",104.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,102.99,,,fee schedule,,,,,,,,
US Extremity Non Vascular,10011165,CDM,0402,RC,76882,CPT,288,EAPG,,,,outpatient,facility,,,738.00,221.40,158.99,371.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,316.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,213.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,235.29,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
US Extremity Non Vascular,10011166,CDM,0402,RC,76882,CPT,,,,,,outpatient,facility,,,738.00,221.40,23.86,627.30,,31.98,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,23.86,,,fee schedule,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,230.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
US Extremity Non Vascular,10011166,CDM,0402,RC,76882,CPT,05522,APC,,,,outpatient,facility,,,738.00,221.40,97.82,234.20,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,214.51,,,fee schedule,,,97.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,211.41,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,97.82,,,fee schedule,,,104.01,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,97.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",104.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,102.99,,,fee schedule,,,,,,,,
US Extremity Non Vascular,10011166,CDM,0402,RC,76882,CPT,288,EAPG,,,,outpatient,facility,,,738.00,221.40,158.99,371.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,316.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,213.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,235.29,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FLUTTER VALVE,10011470,CDM,0270,RC,E0484,HCPCS,,,,,,outpatient,facility,,,52.00,15.60,22.10,44.20,,32.14,,,percent of total billed charges,,,,,,,,service not payable,25.38,,,percent of total billed charges,,,26.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,26.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,22.10,,,percent of total billed charges,,,,,,,,,39.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26.0,,,percent of total billed charges,,,,,,,,service not payable,39.0,,,percent of total billed charges,,,,,,,,service not payable,23.40,,,fee schedule,,,,,,,,,44.20,,,percent of total billed charges,,,23.92,,,percent of total billed charges,,,,,,,,,33.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,33.80,,,percent of total billed charges,,,26.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW LK AXSOS TI 5.0X60MM,10013568,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,737.00,221.10,285.96,626.45,,,,,,,,,,,,,,,,,,,,285.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,368.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,626.45,,,percent of total billed charges,,,331.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X60MM,10013568,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,737.00,221.10,313.22,626.45,,,,,,,,,,,,,service not payable,,,,,,,371.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,552.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,368.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,552.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,626.45,,,percent of total billed charges,,,339.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK AXSOS TI 5.0X70MM,10013569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,737.00,221.10,285.96,626.45,,,,,,,,,,,,,,,,,,,,285.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,368.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,626.45,,,percent of total billed charges,,,331.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X70MM,10013569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,737.00,221.10,313.22,626.45,,,,,,,,,,,,,service not payable,,,,,,,371.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,552.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,368.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,552.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,626.45,,,percent of total billed charges,,,339.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X80MM,10013570,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,154.00,46.20,59.75,130.90,,,,,,,,,,,,,,,,,,,,59.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,,69.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X80MM,10013570,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,154.00,46.20,65.45,130.90,,,,,,,,,,,,,service not payable,,,,,,,77.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,70.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG 10H X_01-730-10-09 X_KLS MARTIN L P,10013573,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2514.00,754.20,975.43,2136.90,,,,,,,,,,,,,,,,,,,,975.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.90,,,percent of total billed charges,,,1131.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG 10H X_01-730-10-09 X_KLS MARTIN L P,10013573,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,,,,,,,,,,,,service not payable,,,,,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CERVICAL SPINE 14MM,10013575,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5799.00,1739.70,2250.01,4929.15,,2841.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2435.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2250.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2464.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4349.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2899.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4929.15,,,percent of total billed charges,,,2609.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CERVICAL SPINE 14MM,10013575,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5799.00,1739.70,2435.58,4929.15,,2841.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2435.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2925.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2464.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4349.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2899.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4349.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4929.15,,,percent of total billed charges,,,2667.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST CERV SPINE 4.25X14MM,10013576,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2524.00,757.20,979.31,2145.40,,,,,,,,,,,,,,,,,,,,979.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1072.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1893.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2145.40,,,percent of total billed charges,,,1135.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST CERV SPINE 4.25X14MM,10013576,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2524.00,757.20,1072.7,2145.40,,,,,,,,,,,,,service not payable,,,,,,,1273.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1072.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1893.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1893.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2145.40,,,percent of total billed charges,,,1161.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT LEGION FEM LFT NRW SZ5,10013577,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT LEGION FEM LFT NRW SZ5,10013577,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUFF OCCLUS W/IZ 5.5CM,10013578,CDM,0278,RC,C1815,HCPCS,,,,,,inpatient,facility,,,19282.00,5784.60,7481.42,16389.70,,9448.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8098.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7481.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8194.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9641.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16389.70,,,percent of total billed charges,,,8676.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUFF OCCLUS W/IZ 5.5CM,10013578,CDM,0278,RC,C1815,HCPCS,,,,,,outpatient,facility,,,19282.00,5784.60,8098.44,16389.70,,9448.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8098.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9725.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8194.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14461.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9641.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14461.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16389.70,,,percent of total billed charges,,,8869.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE SHUNT CERTAS INLINE SIPH,10013579,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,17690.00,5307.00,6863.72,15036.5,,8668.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7429.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6863.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7518.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13267.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8845.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15036.5,,,percent of total billed charges,,,7960.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE SHUNT CERTAS INLINE SIPH,10013579,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,17690.00,5307.00,7429.80,15036.5,,8668.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7429.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8922.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7518.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13267.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8845.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13267.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15036.5,,,percent of total billed charges,,,8137.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY LONG STEM FLX 3IN,10013581,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,222.00,66.60,86.14,188.70,,,,,,,,,,,,,,,,,,,,86.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.70,,,percent of total billed charges,,,99.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY LONG STEM FLX 3IN,10013581,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,222.00,66.60,94.35,188.70,,,,,,,,,,,,,service not payable,,,,,,,111.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,166.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,188.70,,,percent of total billed charges,,,102.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT PESSARY RING W/SUPPORT 1,10013582,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,222.00,66.60,86.14,188.70,,,,,,,,,,,,,,,,,,,,86.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.70,,,percent of total billed charges,,,99.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT PESSARY RING W/SUPPORT 1,10013582,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,222.00,66.60,94.35,188.70,,,,,,,,,,,,,service not payable,,,,,,,111.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,166.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,188.70,,,percent of total billed charges,,,102.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE DENTAL 23GA,10013584,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE DENTAL 23GA,10013584,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 525ML X_MSZ-X525 X_ALLERGAN,10013585,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SUP LAT 3H LFT X_628203 X_STRYKER ORTHOPAEDI,10015096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4431.00,1329.30,1719.23,3766.35,,,,,,,,,,,,,,,,,,,,1719.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1883.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3323.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2215.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3766.35,,,percent of total billed charges,,,1993.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SUP LAT 3H LFT X_628203 X_STRYKER ORTHOPAEDI,10015096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4431.00,1329.30,1883.18,3766.35,,,,,,,,,,,,,service not payable,,,,,,,2235.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1883.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3323.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2215.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3323.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3766.35,,,percent of total billed charges,,,2038.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T10 FT 2.7X12MM,10015097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,715.00,214.50,277.42,607.75,,,,,,,,,,,,,,,,,,,,277.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.75,,,percent of total billed charges,,,321.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T10 FT 2.7X12MM,10015097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,,,,,,,,,,,,service not payable,,,,,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T10 FT 2.7X18MM,10015098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,715.00,214.50,277.42,607.75,,,,,,,,,,,,,,,,,,,,277.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.75,,,percent of total billed charges,,,321.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T10 FT 2.7X18MM,10015098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,,,,,,,,,,,,service not payable,,,,,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 2.7X26MM X_AR-8827L-26 X_ARTHREX INC,10015099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 2.7X26MM X_AR-8827L-26 X_ARTHREX INC,10015099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 2.7X32MM X_AR-8827L-32 X_ARTHREX INC,10015100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 2.7X32MM X_AR-8827L-32 X_ARTHREX INC,10015100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 2.7X36MM X_AR-8827L-36 X_ARTHREX INC,10015101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 2.7X36MM X_AR-8827L-36 X_ARTHREX INC,10015101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 3.5X44MM X_AR-8835-44 X_ARTHREX INC,10015102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 3.5X44MM X_AR-8835-44 X_ARTHREX INC,10015102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE POST DIST TIB 3H X_AR-8963P-03 X_ARTHREX INC,10015103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE POST DIST TIB 3H X_AR-8963P-03 X_ARTHREX INC,10015103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL 8.5MMX33CM X_71655033 X_SMITH NEPHEW,10015105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL 8.5MMX33CM X_71655033 X_SMITH NEPHEW,10015105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.5X20MM X_71645420 X_SMITH NEPHEW,10015106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.5X20MM X_71645420 X_SMITH NEPHEW,10015106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISSECTOR SPACEMAKERPRO BTT OV,10015109,CDM,0278,RC,C1727,HCPCS,,,,,,inpatient,facility,,,2674.00,802.20,1037.51,2272.90,,,,,,,,,,,,,,,,,,,,1037.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1136.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2005.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1337.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.90,,,percent of total billed charges,,,1203.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISSECTOR SPACEMAKERPRO BTT OV,10015109,CDM,0278,RC,C1727,HCPCS,,,,,,outpatient,facility,,,2674.00,802.20,1136.45,2272.90,,,,,,,,,,,,,service not payable,,,,,,,1348.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1136.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2005.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1337.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2005.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2272.90,,,percent of total billed charges,,,1230.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
JACKET RESTRAINT SLEEVE SM X_3360S X_350118,10015117,CDM,0299,RC,E0700,HCPCS,,,,,,outpatient,facility,,,110.00,33.00,46.75,93.5,,67.98,,,percent of total billed charges,,,,,,,,service not payable,53.68,,,percent of total billed charges,,,55.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,55.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,55.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,46.75,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55.0,,,percent of total billed charges,,,,,,,,service not payable,82.5,,,percent of total billed charges,,,,,,,,service not payable,49.5,,,fee schedule,,,,,,,,,93.5,,,percent of total billed charges,,,50.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,55.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW BIO-TENODESIS 4.X10MM,10015448,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIO-TENODESIS 4.X10MM,10015448,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER FEM MOLD SM,10015449,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER FEM MOLD SM,10015449,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GRANDRAS 5FR 2CM X_5580 X_VASCULAR SOLUTIONS,10015450,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,220.01,,,percent of total billed charges,,,,,,,,service not payable,173.73,,,percent of total billed charges,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,231.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,231.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIBIAL 5H RT 62MM X_7282-0905 X_SMITH NEPHEW,10015451,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2077.00,623.10,805.88,1765.45,,,,,,,,,,,,,,,,,,,,805.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,882.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1765.45,,,percent of total billed charges,,,934.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIBIAL 5H RT 62MM X_7282-0905 X_SMITH NEPHEW,10015451,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2077.00,623.10,882.73,1765.45,,,,,,,,,,,,,service not payable,,,,,,,1047.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,882.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1765.45,,,percent of total billed charges,,,955.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX LP TI VAR 3X10MM,10015452,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX LP TI VAR 3X10MM,10015452,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VALGUS STD MTP 10DEG X_AR-8944-10S X_ARTHREX,10015453,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VALGUS STD MTP 10DEG X_AR-8944-10S X_ARTHREX,10015453,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRAPE ARM STERILE,10015458,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.13,242.25,,176.13,,,percent of total billed charges,,,,,,,,service not payable,139.08,,,percent of total billed charges,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.13,,,percent of total billed charges,,,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB KEEL POR MBT SZ3,10015993,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB KEEL POR MBT SZ3,10015993,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT FEM LGN CEM R SZ5N,10015994,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT FEM LGN CEM R SZ5N,10015994,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 2X15MM X_AGX215 X_AXOGEN INC,10015995,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,5083.00,1524.90,1972.20,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1972.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4320.55,,,percent of total billed charges,,,2287.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 2X15MM X_AGX215 X_AXOGEN INC,10015995,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2134.86,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 2X15MM X_AGX215 X_AXOGEN INC,10015995,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,5083.00,1524.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR ICD-VR VIA X_DVAB1D1 X_MEDTRONIC,10015996,CDM,0275,RC,C1722,HCPCS,,,,,,inpatient,facility,,,32467.00,9740.10,12597.20,27596.95,,15908.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13636.14,,,percent of total billed charges,,Paid in addition to inpatient services ,12597.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13798.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24350.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16233.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27596.95,,,percent of total billed charges,,,14610.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR ICD-VR VIA X_DVAB1D1 X_MEDTRONIC,10015996,CDM,0275,RC,C1722,HCPCS,,,,,,outpatient,facility,,,32467.00,9740.10,13636.14,27596.95,,15908.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13636.14,,,percent of total billed charges,,Paid in addition to outpatient services ,16376.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13798.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24350.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16233.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24350.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27596.95,,,percent of total billed charges,,,14934.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT AVANCE NERVE 2-3MM 50MM,10016285,CDM,0278,RC,C9352,HCPCS,,,,,,inpatient,facility,,,14178.00,4253.40,5501.06,12051.30,,6947.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5954.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5501.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6025.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10633.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7089.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12051.30,,,percent of total billed charges,,,6380.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT AVANCE NERVE 2-3MM 50MM,10016285,CDM,0278,RC,C9352,HCPCS,,,,,,outpatient,facility,,,14178.00,4253.40,5954.76,12051.30,,6947.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5954.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7151.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6025.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10633.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7089.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10633.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12051.30,,,percent of total billed charges,,,6521.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT AVANCE NERVE 2-3MM 50MM,10016285,CDM,0278,RC,C9352,HCPCS,455,EAPG,,,,outpatient,facility,,,14178.00,4253.40,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT ANCHOR LEAD SENZA SPNL CRD,10016289,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT ANCHOR LEAD SENZA SPNL CRD,10016289,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT LEAD PERC SENZA 5.0MM BLU X_LEAD1058-70B X_NEV,10016292,CDM,0278,RC,C1897,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT LEAD PERC SENZA 5.0MM BLU X_LEAD1058-70B X_NEV,10016292,CDM,0278,RC,C1897,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VASC ACUITY STR 182C,10016294,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Aspiration or release of vitreous sub retinal or,10017261,CDM,0450,RC,67015,CPT,,,,,,outpatient,facility,,,4814.00,1444.20,774.0,4091.90,,2975.05,,,percent of total billed charges,,,,,,,,,2349.23,,,percent of total billed charges,,,2428.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4091.90,,,percent of total billed charges,,,2214.44,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Aspiration or release of vitreous sub retinal or,10017261,CDM,0450,RC,67015,CPT,05491,APC,,,,outpatient,facility,,,4814.00,1444.20,1048.93,5023.32,,,,,,,,2187.15,,,fee schedule,,,,,,,,,,,,,,,4601.01,,,fee schedule,,,1048.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",2230.89,,,fee schedule,,,5023.32,,,fee schedule,,,,,,,,,2187.15,,,fee schedule,,,,,,,,,,,,,,,4534.33,,,fee schedule,,,,,,,,,2187.15,,,fee schedule,,,1048.93,,,fee schedule,,,2230.89,,,fee schedule,,,,,,,,,2187.15,,,fee schedule,,,,,,,,,1048.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",2230.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2187.15,,,fee schedule,,,,,,,,,,,,,,,2187.15,,,fee schedule,,,,,,,,,2208.93,,,fee schedule,,,,,,,,
Aspiration or release of vitreous sub retinal or,10017261,CDM,0450,RC,67015,CPT,238,EAPG,,,,outpatient,facility,,,4814.00,1444.20,4544.88,8802.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8750.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7437.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4544.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4544.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4544.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8002.34,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,8802.57,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PUTTY BIO-DBM 2.5ML,10017290,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,2254.00,676.20,874.55,1915.90,,,,,,,,,,,,,,,,,,,,874.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1690.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1127.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1915.90,,,percent of total billed charges,,,1014.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY BIO-DBM 2.5ML,10017290,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,2254.00,676.20,957.95,1915.90,,,,,,,,,,,,,service not payable,,,,,,,1136.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,957.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1690.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1127.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1690.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1915.90,,,percent of total billed charges,,,1036.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO-DBM 2.5ML,10017290,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,2254.00,676.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINAL TI 3.5X50MM,10017291,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINAL TI 3.5X50MM,10017291,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 3.5X12MM X_48558312 X_STRYKER ORTHOPAEDICS,10017292,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2755.00,826.50,1068.94,2341.75,,,,,,,,,,,,,,,,,,,,1068.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.75,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 3.5X12MM X_48558312 X_STRYKER ORTHOPAEDICS,10017292,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2755.00,826.50,1170.88,2341.75,,,,,,,,,,,,,service not payable,,,,,,,1389.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2341.75,,,percent of total billed charges,,,1267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.0X12MM X_48558412 X_STRYKER ORTHOPAEDICS,10017293,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2755.00,826.50,1068.94,2341.75,,,,,,,,,,,,,,,,,,,,1068.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.75,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.0X12MM X_48558412 X_STRYKER ORTHOPAEDICS,10017293,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2755.00,826.50,1170.88,2341.75,,,,,,,,,,,,,service not payable,,,,,,,1389.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2341.75,,,percent of total billed charges,,,1267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM TMT VBR-S 11X14X23.0MM,10017295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM TMT VBR-S 11X14X23.0MM,10017295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.7X16MM X_657016 X_STRYKER ORTHOPAE,10017296,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1361.00,408.30,528.07,1156.85,,,,,,,,,,,,,,,,,,,,528.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.85,,,percent of total billed charges,,,612.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.7X16MM X_657016 X_STRYKER ORTHOPAE,10017296,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1361.00,408.30,578.42,1156.85,,,,,,,,,,,,,service not payable,,,,,,,686.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.85,,,percent of total billed charges,,,626.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T10 FT 2.7X16MM,10017297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T10 FT 2.7X16MM,10017297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HOOK 7H 20MM RT X_628557S X_STRYKER ORTHOPAE,10017298,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4092.00,1227.60,1587.70,3478.20,,,,,,,,,,,,,,,,,,,,1587.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1739.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3069.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2046.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3478.20,,,percent of total billed charges,,,1841.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HOOK 7H 20MM RT X_628557S X_STRYKER ORTHOPAE,10017298,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4092.00,1227.60,1739.10,3478.20,,,,,,,,,,,,,service not payable,,,,,,,2064.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1739.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3069.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2046.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3069.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3478.20,,,percent of total billed charges,,,1882.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CURVED TI 5.5X75MM,10017299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CURVED TI 5.5X75MM,10017299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CURVED TI 5.5X80MM,10017300,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CURVED TI 5.5X80MM,10017300,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 44X21MM,10017301,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11782.00,3534.60,4571.42,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4571.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10014.70,,,percent of total billed charges,,,5301.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 44X21MM,10017301,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11782.00,3534.60,4948.44,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5942.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10014.70,,,percent of total billed charges,,,5419.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 5X28MM X_71822028 X_SMITH NEPHEW,10017302,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,253.00,75.90,98.16,215.05,,,,,,,,,,,,,,,,,,,,98.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.05,,,percent of total billed charges,,,113.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5X28MM X_71822028 X_SMITH NEPHEW,10017302,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,253.00,75.90,107.52,215.05,,,,,,,,,,,,,service not payable,,,,,,,127.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,189.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,215.05,,,percent of total billed charges,,,116.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 5X36MM X_71822036 X_SMITH NEPHEW,10017303,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,253.00,75.90,98.16,215.05,,,,,,,,,,,,,,,,,,,,98.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.05,,,percent of total billed charges,,,113.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5X36MM X_71822036 X_SMITH NEPHEW,10017303,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,253.00,75.90,107.52,215.05,,,,,,,,,,,,,service not payable,,,,,,,127.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,189.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,215.05,,,percent of total billed charges,,,116.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 5X38MM X_71822038 X_SMITH NEPHEW,10017304,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,253.00,75.90,98.16,215.05,,,,,,,,,,,,,,,,,,,,98.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.05,,,percent of total billed charges,,,113.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5X38MM X_71822038 X_SMITH NEPHEW,10017304,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,253.00,75.90,107.52,215.05,,,,,,,,,,,,,service not payable,,,,,,,127.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,189.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,215.05,,,percent of total billed charges,,,116.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 5X38MM PT X_71821138 X_SMITH NEPHEW,10017305,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,253.00,75.90,98.16,215.05,,,,,,,,,,,,,,,,,,,,98.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.05,,,percent of total billed charges,,,113.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5X38MM PT X_71821138 X_SMITH NEPHEW,10017305,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,253.00,75.90,107.52,215.05,,,,,,,,,,,,,service not payable,,,,,,,127.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,107.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,189.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,126.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,189.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,215.05,,,percent of total billed charges,,,116.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB DYNAGEN CARDIOVERT CRT-D,10017307,CDM,0278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,42944.00,12883.20,16662.27,36502.40,,21042.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18036.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16662.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32208.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21472.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36502.40,,,percent of total billed charges,,,19324.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB DYNAGEN CARDIOVERT CRT-D,10017307,CDM,0278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,42944.00,12883.20,18036.48,36502.40,,21042.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18036.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21660.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18251.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32208.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21472.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32208.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36502.40,,,percent of total billed charges,,,19754.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH FOLEY BARDEX UM TRAY 16FR,10017308,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,119.00,35.70,50.58,101.15,,73.54,,,percent of total billed charges,,,,,,,,service not payable,58.07,,,percent of total billed charges,,,60.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,50.58,,,percent of total billed charges,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,,,,,,service not payable,89.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,101.15,,,percent of total billed charges,,,54.74,,,percent of total billed charges,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,77.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH FOLEY TMPSNS UM TRAY 16FR,10017309,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,184.00,55.20,78.20,156.40,,113.71,,,percent of total billed charges,,,,,,,,service not payable,89.79,,,percent of total billed charges,,,92.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,78.20,,,percent of total billed charges,,,,,,,,,138.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,92.0,,,percent of total billed charges,,,,,,,,service not payable,138.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,156.40,,,percent of total billed charges,,,84.64,,,percent of total billed charges,,,,,,,,,119.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,119.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 320ML X_SCL-320 X_ALLERGA,10017311,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 320ML X_SCL-320 X_ALLERGA,10017311,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 350ML X_SCL-350 X_ALLERGA,10017312,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 350ML X_SCL-350 X_ALLERGA,10017312,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 380ML X_SCL-380 X_ALLERGA,10017313,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 380ML X_SCL-380 X_ALLERGA,10017313,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 360ML X_SCLP-360 X_ALLER,10017314,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 360ML X_SCLP-360 X_ALLER,10017314,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 400ML X_SCLP-400 X_ALLER,10017315,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 400ML X_SCLP-400 X_ALLER,10017315,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 440ML X_SCLP-440 X_ALLER,10017316,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 440ML X_SCLP-440 X_ALLER,10017316,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 445ML X_SCM-445 X_ALLERGA,10017317,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 445ML X_SCM-445 X_ALLERGA,10017317,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 485ML X_SCM-485 X_ALLERGA,10017318,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 485ML X_SCM-485 X_ALLERGA,10017318,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 520ML X_SCM-520 X_ALLERGA,10017319,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 520ML X_SCM-520 X_ALLERGA,10017319,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 320ML X_MSZ-L320 X_ALLERGAN,10017320,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 320ML X_MSZ-L320 X_ALLERGAN,10017320,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 350ML X_MSZ-L350 X_ALLERGAN,10017321,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 350ML X_MSZ-L350 X_ALLERGAN,10017321,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 380ML X_MSZ-L380 X_ALLERGAN,10017322,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 380ML X_MSZ-L380 X_ALLERGAN,10017322,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 360ML X_MSZ-LP360 X_ALLERG,10017323,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 360ML X_MSZ-LP360 X_ALLERG,10017323,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 400ML X_MSZ-LP400 X_ALLERG,10017324,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 400ML X_MSZ-LP400 X_ALLERG,10017324,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 440ML X_MSZ-LP440 X_ALLERG,10017325,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 440ML X_MSZ-LP440 X_ALLERG,10017325,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCM 445ML X_MSZ-M445 X_ALLERGAN,10017326,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCM 520ML X_MSZ-M520 X_ALLERGAN,10017327,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCM 485ML X_MSZ-M485 X_ALLERGAN,10017328,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L BONE 8H LT 1.0X0.6MM X_25-333-08-09 X_KLS,10017332,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,738.00,221.40,286.34,627.30,,,,,,,,,,,,,,,,,,,,286.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,332.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L BONE 8H LT 1.0X0.6MM X_25-333-08-09 X_KLS,10017332,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,,,,,,,,,,,,service not payable,,,,,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y 1MM 6H MICRO X_25-342-06-09 X_KLS MARTIN L,10017333,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,791.00,237.30,306.91,672.35,,,,,,,,,,,,,,,,,,,,306.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,593.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,395.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.35,,,percent of total billed charges,,,355.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y 1MM 6H MICRO X_25-342-06-09 X_KLS MARTIN L,10017333,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,791.00,237.30,336.18,672.35,,,,,,,,,,,,,service not payable,,,,,,,398.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,336.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,593.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,395.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,593.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,672.35,,,percent of total billed charges,,,363.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ST LP 16H CP TITANI X_25-316-01-09 X_KLS MAR,10017334,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,409.00,122.70,158.69,347.65,,,,,,,,,,,,,,,,,,,,158.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,306.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.65,,,percent of total billed charges,,,184.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ST LP 16H CP TITANI X_25-316-01-09 X_KLS MAR,10017334,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,409.00,122.70,173.82,347.65,,,,,,,,,,,,,service not payable,,,,,,,206.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,173.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,306.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,306.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,347.65,,,percent of total billed charges,,,188.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 110ML X_SCL-110 X_ALLERGA,10017335,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 110ML X_SCL-110 X_ALLERGA,10017335,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 125ML X_SCL-125 X_ALLERGA,10017336,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 125ML X_SCL-125 X_ALLERGA,10017336,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 140ML X_SCL-140 X_ALLERGA,10017337,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 140ML X_SCL-140 X_ALLERGA,10017337,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 170ML X_SCL-170 X_ALLERGA,10017338,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 170ML X_SCL-170 X_ALLERGA,10017338,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 200ML X_SCL-200 X_ALLERGA,10017339,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 200ML X_SCL-200 X_ALLERGA,10017339,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 230ML X_SCL-230 X_ALLERGA,10017340,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 230ML X_SCL-230 X_ALLERGA,10017340,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 260ML X_SCL-260 X_ALLERGA,10017341,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 260ML X_SCL-260 X_ALLERGA,10017341,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 290ML X_SCL-290 X_ALLERGA,10017342,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 290ML X_SCL-290 X_ALLERGA,10017342,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 410ML X_SCL-410 X_ALLERGA,10017343,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 410ML X_SCL-410 X_ALLERGA,10017343,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 460ML X_SCL-460 X_ALLERGA,10017344,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 460ML X_SCL-460 X_ALLERGA,10017344,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 510ML X_SCL-510 X_ALLERGA,10017345,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 510ML X_SCL-510 X_ALLERGA,10017345,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 560ML X_SCL-560 X_ALLERGA,10017346,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 560ML X_SCL-560 X_ALLERGA,10017346,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCL 610ML X_SCL-610 X_ALLERGA,10017347,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCL 610ML X_SCL-610 X_ALLERGA,10017347,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LOCK SAG BONE 6H 12MM X_55-10566 X_STRYKER,10017350,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1345.00,403.50,521.86,1143.25,,,,,,,,,,,,,,,,,,,,521.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1008.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,672.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1143.25,,,percent of total billed charges,,,605.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LOCK SAG BONE 6H 12MM X_55-10566 X_STRYKER,10017350,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1345.00,403.50,571.62,1143.25,,,,,,,,,,,,,service not payable,,,,,,,678.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,571.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1008.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,672.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1008.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1143.25,,,percent of total billed charges,,,618.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MONOAXIAL 4.0X20MM,10017351,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MONOAXIAL 4.0X20MM,10017351,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 125ML X_SCLP-125 X_ALLER,10017354,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 125ML X_SCLP-125 X_ALLER,10017354,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 146ML X_SCLP-146 X_ALLER,10017355,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 146ML X_SCLP-146 X_ALLER,10017355,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 165ML X_SCLP-165 X_ALLER,10017356,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 165ML X_SCLP-165 X_ALLER,10017356,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 190ML X_SCLP-190 X_ALLER,10017357,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 190ML X_SCLP-190 X_ALLER,10017357,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 205ML X_SCLP-205 X_ALLER,10017358,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 205ML X_SCLP-205 X_ALLER,10017358,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 220ML X_SCLP-220 X_ALLER,10017359,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 220ML X_SCLP-220 X_ALLER,10017359,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCLP 235CC,10017360,CDM,0272,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.17,3052.35,,2219.24,,,percent of total billed charges,,,,,,,,service not payable,1752.41,,,percent of total billed charges,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.17,,,percent of total billed charges,,,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,2334.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2334.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCLP 250CC,10017361,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCLP 250CC,10017361,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCLP 265CC,10017362,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCLP 265CC,10017362,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCLP 280CC,10017363,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCLP 280CC,10017363,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCLP 300CC,10017364,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCLP 300CC,10017364,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 320ML X_SCLP-320 X_ALLER,10017365,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 320ML X_SCLP-320 X_ALLER,10017365,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 340ML X_SCLP-340 X_ALLER,10017366,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 340ML X_SCLP-340 X_ALLER,10017366,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 490ML X_SCLP-490 X_ALLER,10017367,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 490ML X_SCLP-490 X_ALLER,10017367,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 540ML X_SCLP-540 X_ALLER,10017368,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 540ML X_SCLP-540 X_ALLER,10017368,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 590ML X_SCLP-590 X_ALLER,10017369,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 590ML X_SCLP-590 X_ALLER,10017369,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCLP 640ML X_SCLP-640 X_ALLER,10017370,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCLP 640ML X_SCLP-640 X_ALLER,10017370,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCM 140CC,10017371,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCM 140CC,10017371,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 175ML X_SCM-175 X_ALLERGA,10017372,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 175ML X_SCM-175 X_ALLERGA,10017372,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 195ML X_SCM-195 X_ALLERGA,10017373,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 195ML X_SCM-195 X_ALLERGA,10017373,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 210ML X_SCM-210 X_ALLERGA,10017374,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 210ML X_SCM-210 X_ALLERGA,10017374,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCM 240CC,10017375,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCM 240CC,10017375,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCM 255CC,10017376,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCM 255CC,10017376,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 275ML X_SCM-275 X_ALLERGA,10017377,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 275ML X_SCM-275 X_ALLERGA,10017377,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCM 295CC,10017378,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCM 295CC,10017378,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST INSPIRA SCM 310CC,10017379,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST INSPIRA SCM 310CC,10017379,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 330ML X_SCM-330 X_ALLERGA,10017380,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 330ML X_SCM-330 X_ALLERGA,10017380,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 345ML X_SCM-345 X_ALLERGA,10017381,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 345ML X_SCM-345 X_ALLERGA,10017381,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 360ML X_SCM-360 X_ALLERGA,10017382,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 360ML X_SCM-360 X_ALLERGA,10017382,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 375ML X_SCM-375 X_ALLERGA,10017383,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 375ML X_SCM-375 X_ALLERGA,10017383,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 405ML X_SCM-405 X_ALLERGA,10017384,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 405ML X_SCM-405 X_ALLERGA,10017384,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 560ML X_SCM-560 X_ALLERGA,10017385,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 560ML X_SCM-560 X_ALLERGA,10017385,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 600ML X_SCM-600 X_ALLERGA,10017386,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 600ML X_SCM-600 X_ALLERGA,10017386,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 640ML X_SCM-640 X_ALLERGA,10017387,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 640ML X_SCM-640 X_ALLERGA,10017387,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 685ML X_SCM-685 X_ALLERGA,10017388,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 685ML X_SCM-685 X_ALLERGA,10017388,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SCM 755ML X_SCM-755 X_ALLERGA,10017389,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SCM 755ML X_SCM-755 X_ALLERGA,10017389,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 205ML X_MSZ-X205 X_ALLERGAN,10017390,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 205ML X_MSZ-X205 X_ALLERGAN,10017390,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 225ML X_MSZ-X225 X_ALLERGAN,10017391,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 225ML X_MSZ-X225 X_ALLERGAN,10017391,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 255ML X_MSZ-X255 X_ALLERGAN,10017392,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 255ML X_MSZ-X255 X_ALLERGAN,10017392,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 285ML X_MSZ-X285 X_ALLERGAN,10017393,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 285ML X_MSZ-X285 X_ALLERGAN,10017393,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 310ML X_MSZ-X310 X_ALLERGAN,10017394,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 310ML X_MSZ-X310 X_ALLERGAN,10017394,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 340CC,10017395,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 340CC,10017395,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 375ML X_MSZ-X375 X_ALLERGAN,10017396,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 375ML X_MSZ-X375 X_ALLERGAN,10017396,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 400ML X_MSZ-X400 X_ALLERGAN,10017397,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 400ML X_MSZ-X400 X_ALLERGAN,10017397,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 140ML X_MSZ-M140 X_ALLERGAN,10017398,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 140ML X_MSZ-M140 X_ALLERGAN,10017398,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 175ML X_MSZ-M175 X_ALLERGAN,10017399,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 175ML X_MSZ-M175 X_ALLERGAN,10017399,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 195ML X_MSZ-M195 X_ALLERGAN,10017400,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 195ML X_MSZ-M195 X_ALLERGAN,10017400,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 310ML X_MSZ-M310 X_ALLERGAN,10017401,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 310ML X_MSZ-M310 X_ALLERGAN,10017401,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 330ML X_MSZ-M330 X_ALLERGAN,10017402,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 330ML X_MSZ-M330 X_ALLERGAN,10017402,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 345ML X_MSZ-M345 X_ALLERGAN,10017403,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 345ML X_MSZ-M345 X_ALLERGAN,10017403,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 360ML X_MSZ-M360 X_ALLERGAN,10017404,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 360ML X_MSZ-M360 X_ALLERGAN,10017404,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 375ML X_MSZ-M375 X_ALLERGAN,10017405,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 375ML X_MSZ-M375 X_ALLERGAN,10017405,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 405ML X_MSZ-M405 X_ALLERGAN,10017406,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 405ML X_MSZ-M405 X_ALLERGAN,10017406,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 560ML X_MSZ-M560 X_ALLERGAN,10017407,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 560ML X_MSZ-M560 X_ALLERGAN,10017407,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 600ML X_MSZ-M600 X_ALLERGAN,10017408,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 600ML X_MSZ-M600 X_ALLERGAN,10017408,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 640ML X_MSZ-M640 X_ALLERGAN,10017409,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 640ML X_MSZ-M640 X_ALLERGAN,10017409,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 685ML X_MSZ-M685 X_ALLERGAN,10017410,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 685ML X_MSZ-M685 X_ALLERGAN,10017410,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRM 755ML X_MSZ-M755 X_ALLERGAN,10017411,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRM 755ML X_MSZ-M755 X_ALLERGAN,10017411,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 110ML X_MSZ-L110 X_ALLERGAN,10017412,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 110ML X_MSZ-L110 X_ALLERGAN,10017412,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 125ML X_MSZ-L125 X_ALLERGAN,10017413,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 125ML X_MSZ-L125 X_ALLERGAN,10017413,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 140ML X_MSZ-L140 X_ALLERGAN,10017414,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 140ML X_MSZ-L140 X_ALLERGAN,10017414,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 260ML X_MSZ-L260 X_ALLERGAN,10017415,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 260ML X_MSZ-L260 X_ALLERGAN,10017415,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 290ML X_MSZ-L290 X_ALLERGAN,10017416,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 290ML X_MSZ-L290 X_ALLERGAN,10017416,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 410ML X_MSZ-L410 X_ALLERGAN,10017417,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 410ML X_MSZ-L410 X_ALLERGAN,10017417,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 460ML X_MSZ-L460 X_ALLERGAN,10017418,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 460ML X_MSZ-L460 X_ALLERGAN,10017418,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 510ML X_MSZ-L510 X_ALLERGAN,10017419,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 510ML X_MSZ-L510 X_ALLERGAN,10017419,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 560ML X_MSZ-L560 X_ALLERGAN,10017420,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 560ML X_MSZ-L560 X_ALLERGAN,10017420,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCL 610ML X_MSZ-L610 X_ALLERGAN,10017421,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCL 610ML X_MSZ-L610 X_ALLERGAN,10017421,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 125ML X_MSZ-LP125 X_ALLERG,10017422,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 125ML X_MSZ-LP125 X_ALLERG,10017422,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 145ML X_MSZ-LP145 X_ALLERG,10017423,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 145ML X_MSZ-LP145 X_ALLERG,10017423,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 165ML X_MSZ-LP165 X_ALLERG,10017424,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 165ML X_MSZ-LP165 X_ALLERG,10017424,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 190ML X_MSZ-LP190 X_ALLERG,10017425,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 190ML X_MSZ-LP190 X_ALLERG,10017425,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 280ML X_MSZ-LP280 X_ALLERG,10017426,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 280ML X_MSZ-LP280 X_ALLERG,10017426,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 300ML X_MSZ-LP300 X_ALLERG,10017427,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 300ML X_MSZ-LP300 X_ALLERG,10017427,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 320ML X_MSZ-LP320 X_ALLERG,10017428,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 320ML X_MSZ-LP320 X_ALLERG,10017428,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 340ML X_MSZ-LP340 X_ALLERG,10017429,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 340ML X_MSZ-LP340 X_ALLERG,10017429,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 490ML X_MSZ-LP490 X_ALLERG,10017430,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 490ML X_MSZ-LP490 X_ALLERG,10017430,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 540CC,10017431,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 540CC,10017431,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 590ML X_MSZ-LP590 X_ALLERG,10017432,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 590ML X_MSZ-LP590 X_ALLERG,10017432,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SCLP 640ML X_MSZ-LP640 X_ALLERG,10017433,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SCLP 640ML X_MSZ-LP640 X_ALLERG,10017433,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON LUTONIX DRUG 5FR 40X60MM 130CM X_LX35,10019710,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LUTONIX DRUG 5FR 40X60MM 130CM X_LX35,10019710,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER PACING LEAD SELECT X_C315J X_MEDTRONIC,10019711,CDM,0270,RC,C1892,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.13,2044.25,,1486.29,,,percent of total billed charges,,,,,,,,service not payable,1173.64,,,percent of total billed charges,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.13,,,percent of total billed charges,,,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CVD 5.5X150MM X_124.615 X_GLOBUS,10019712,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CVD 5.5X150MM X_124.615 X_GLOBUS,10019712,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX30CM LT 125DEG X_71675505 X_SMITH NEPHEW,10019713,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX30CM LT 125DEG X_71675505 X_SMITH NEPHEW,10019713,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORT 2.7X38MM X_AR-8827-38 X_ARTHREX INC,10019715,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORT 2.7X38MM X_AR-8827-38 X_ARTHREX INC,10019715,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CERV SPINE TI 3.5X12MM X_48558312 X_STRYKER,10019716,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2755.00,826.50,1068.94,2341.75,,,,,,,,,,,,,,,,,,,,1068.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.75,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CERV SPINE TI 3.5X12MM X_48558312 X_STRYKER,10019716,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2755.00,826.50,1170.88,2341.75,,,,,,,,,,,,,service not payable,,,,,,,1389.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2341.75,,,percent of total billed charges,,,1267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PASTE GRAFT SPINE DBM 2ML,10019718,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,1793.00,537.90,695.68,1524.05,,,,,,,,,,,,,,,,,,,,695.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,762.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1344.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,896.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1524.05,,,percent of total billed charges,,,806.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PASTE GRAFT SPINE DBM 2ML,10019718,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,1793.00,537.90,762.02,1524.05,,,,,,,,,,,,,service not payable,,,,,,,904.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,762.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1344.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,896.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1344.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1524.05,,,percent of total billed charges,,,824.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PASTE GRAFT SPINE DBM 2ML,10019718,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,1793.00,537.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP 2.5X30MM X_141-2530 X_STRYKER ORTHOPAED,10019862,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1329.00,398.70,515.65,1129.65,,,,,,,,,,,,,,,,,,,,515.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,564.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,996.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,664.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1129.65,,,percent of total billed charges,,,598.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP 2.5X30MM X_141-2530 X_STRYKER ORTHOPAED,10019862,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1329.00,398.70,564.82,1129.65,,,,,,,,,,,,,service not payable,,,,,,,670.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,564.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,996.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,664.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,996.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1129.65,,,percent of total billed charges,,,611.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD DEFIB CATH STR 7.5X86CM,10019863,CDM,0278,RC,C1900,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD DEFIB CATH STR 7.5X86CM,10019863,CDM,0278,RC,C1900,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE ACUITY 7FRX65CM,10019864,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,762.00,228.60,323.85,647.70,,470.92,,,percent of total billed charges,,,,,,,,service not payable,371.86,,,percent of total billed charges,,,384.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,323.85,,,percent of total billed charges,,,,,,,,,571.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,381.0,,,percent of total billed charges,,,,,,,,service not payable,571.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,647.70,,,percent of total billed charges,,,350.52,,,percent of total billed charges,,,,,,,,,495.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,495.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5X42MM X_AR-8935L-42 X_ARTHREX INC,10019868,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X42MM X_AR-8935L-42 X_ARTHREX INC,10019868,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FLOW COUPLER W/DOPPLER 3.5MM X_GEM2755-FC X_SYNOVI,10019869,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLOW COUPLER W/DOPPLER 3.5MM X_GEM2755-FC X_SYNOVI,10019869,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DURAMATRIX ONLAY PLUS 2X2IN X_DMOP22 X_STRYKER,10019870,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3077.00,923.10,1193.88,2615.45,,,,,,,,,,,,,,,,,,,,1193.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1307.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2307.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1538.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2615.45,,,percent of total billed charges,,,1384.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DURAMATRIX ONLAY PLUS 2X2IN X_DMOP22 X_STRYKER,10019870,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3077.00,923.10,1307.72,2615.45,,,,,,,,,,,,,service not payable,,,,,,,1552.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1307.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2307.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1538.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2307.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2615.45,,,percent of total billed charges,,,1415.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK TI BONE 1.5MM,10019938,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2857.00,857.10,1108.52,2428.45,,,,,,,,,,,,,,,,,,,,1108.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1214.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2142.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1428.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2428.45,,,percent of total billed charges,,,1285.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK TI BONE 1.5MM,10019938,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2857.00,857.10,1214.22,2428.45,,,,,,,,,,,,,service not payable,,,,,,,1441.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1214.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2142.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1428.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2142.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2428.45,,,percent of total billed charges,,,1314.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP ACUTWIST 12MM X_AI-0012-S X_ACUMED,10021096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1045.00,313.50,405.46,888.25,,,,,,,,,,,,,,,,,,,,405.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,783.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,522.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,888.25,,,percent of total billed charges,,,470.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP ACUTWIST 12MM X_AI-0012-S X_ACUMED,10021096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1045.00,313.50,444.12,888.25,,,,,,,,,,,,,service not payable,,,,,,,527.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,444.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,783.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,522.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,783.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,888.25,,,percent of total billed charges,,,480.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CEM AS VEGA F4N R,10021097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CEM AS VEGA F4N R,10021097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPANT FLAT INSERT 11MM,10021098,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,29504.00,8851.20,11447.55,25078.40,,14456.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12391.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11447.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12539.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22128.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14752.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25078.40,,,percent of total billed charges,,,13276.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPANT FLAT INSERT 11MM,10021098,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,29504.00,8851.20,12391.68,25078.40,,14456.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12391.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14881.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12539.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22128.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14752.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22128.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,25078.40,,,percent of total billed charges,,,13571.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE 133MX W/TB 400ML X_133MX-12-T X_AL,10021099,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4574.00,1372.20,1774.71,3887.90,,,,,,,,,,,,,,,,,,,,1774.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.90,,,percent of total billed charges,,,2058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE 133MX W/TB 400ML X_133MX-12-T X_AL,10021099,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,,,,,,,,,,,,service not payable,,,,,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE NOVASURE ADV 6MM,10021101,CDM,0272,RC,C2618,HCPCS,,,,,,outpatient,facility,,,3666.00,1099.80,1558.05,3116.10,,2265.59,,,percent of total billed charges,,,,,,,,service not payable,1789.01,,,percent of total billed charges,,,1849.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1558.05,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1833.0,,,percent of total billed charges,,,,,,,,service not payable,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3116.10,,,percent of total billed charges,,,1686.36,,,percent of total billed charges,,,,,,,,,2382.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2382.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER QUADRIPOLAR FIX 6F 110CM X_041002JM X_MED,10021102,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,422.09,,,percent of total billed charges,,,,,,,,service not payable,333.30,,,percent of total billed charges,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DECAPOLAR STEER 7F 90CM X_043302M X_MEDTR,10021103,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA SRX 445ML X_MSZ-X495 X_ALLERGAN,10021105,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA SRX 445ML X_MSZ-X495 X_ALLERGAN,10021105,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Unlisted Urinary System Procedure,10023096,CDM,0450,RC,53899,CPT,,,,,,outpatient,facility,,,657.00,197.10,302.22,880.0,,406.03,,,percent of total billed charges,,,,,,,,,320.62,,,percent of total billed charges,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Unlisted Urinary System Procedure,10023096,CDM,0450,RC,53899,CPT,05371,APC,,,,outpatient,facility,,,657.00,197.10,111.86,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,111.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,111.86,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,111.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
Unlisted Urinary System Procedure,10023096,CDM,0450,RC,53899,CPT,170,EAPG,,,,outpatient,facility,,,657.00,197.10,657.0,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,657.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,657.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW HEADED 2.5X36MM X_IC2536 X_STRYKER ORTHOPAED,10025097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1842.00,552.60,714.70,1565.7,,,,,,,,,,,,,,,,,,,,714.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1565.7,,,percent of total billed charges,,,828.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADED 2.5X36MM X_IC2536 X_STRYKER ORTHOPAED,10025097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1842.00,552.60,782.85,1565.7,,,,,,,,,,,,,service not payable,,,,,,,929.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1565.7,,,percent of total billed charges,,,847.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 2.5X38MM,10025098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2566.00,769.80,995.61,2181.10,,,,,,,,,,,,,,,,,,,,995.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.10,,,percent of total billed charges,,,1154.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X38MM,10025098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2566.00,769.80,1090.55,2181.10,,,,,,,,,,,,,service not payable,,,,,,,1294.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2181.10,,,percent of total billed charges,,,1180.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KWIRE KIRSCHNER NON-TH 2.5MM,10025101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,351.00,105.30,136.19,298.35,,,,,,,,,,,,,,,,,,,,136.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,263.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,175.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.35,,,percent of total billed charges,,,157.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KWIRE KIRSCHNER NON-TH 2.5MM,10025101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,351.00,105.30,149.17,298.35,,,,,,,,,,,,,service not payable,,,,,,,177.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,149.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,263.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,175.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,263.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,298.35,,,percent of total billed charges,,,161.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SUPERA 6.0X150X120 X_S-60-150-120-P6 X_ABBOT,10025102,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SUPERA 6.0X150X120 X_S-60-150-120-P6 X_ABBOT,10025102,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE ENDOAC HF16FR 62CMX28MM,10025104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5773.00,1731.90,2239.92,4907.05,,2828.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2424.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2239.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2453.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4329.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2886.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4907.05,,,percent of total billed charges,,,2597.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE ENDOAC HF16FR 62CMX28MM,10025104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5773.00,1731.90,2424.66,4907.05,,2828.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2424.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2911.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2453.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4329.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2886.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4329.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4907.05,,,percent of total billed charges,,,2655.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CASSETTE ENDOANCH HELI FX SY,10025105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,15572.00,4671.60,6041.94,13236.20,,7630.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6540.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6041.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6618.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7786.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13236.20,,,percent of total billed charges,,,7007.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CASSETTE ENDOANCH HELI FX SY,10025105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,15572.00,4671.60,6540.24,13236.20,,7630.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6540.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7854.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6618.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11679.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7786.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11679.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13236.20,,,percent of total billed charges,,,7163.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG CANN TPR 6.5X55MM,10025106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3462.00,1038.60,1343.26,2942.70,,,,,,,,,,,,,,,,,,,,1343.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1471.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2596.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1731.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2942.70,,,percent of total billed charges,,,1557.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG CANN TPR 6.5X55MM,10025106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3462.00,1038.60,1471.35,2942.70,,,,,,,,,,,,,service not payable,,,,,,,1746.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1471.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2596.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1731.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2596.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2942.70,,,percent of total billed charges,,,1592.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM GLBL UNI SZ44X18,10025108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM GLBL UNI SZ44X18,10025108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE .017 TIP 335CM,10025113,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,506.76,,,percent of total billed charges,,,,,,,,service not payable,400.16,,,percent of total billed charges,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RELINE O OCOCR 5.5X50MM,10025256,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1071.00,321.30,415.55,910.35,,,,,,,,,,,,,,,,,,,,415.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.35,,,percent of total billed charges,,,481.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RELINE O OCOCR 5.5X50MM,10025256,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1071.00,321.30,455.18,910.35,,,,,,,,,,,,,service not payable,,,,,,,540.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,455.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,803.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,535.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,803.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,910.35,,,percent of total billed charges,,,492.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT LEGION FEM RT SZ6,10025257,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT LEGION FEM RT SZ6,10025257,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 18F 33CM,10025259,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2640.00,792.00,1122.0,2244.0,,1631.52,,,percent of total billed charges,,,,,,,,service not payable,1288.32,,,percent of total billed charges,,,1331.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,,1980.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1320.0,,,percent of total billed charges,,,,,,,,service not payable,1980.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2244.0,,,percent of total billed charges,,,1214.40,,,percent of total billed charges,,,,,,,,,1716.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1716.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON EXPAND 11X59MM 135CM,10025260,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD VIRAGE CVD TI 3.5 X 35MM,10025261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD VIRAGE CVD TI 3.5 X 35MM,10025261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD VIRAGE CVD TI 3.5 X 30MM,10025262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD VIRAGE CVD TI 3.5 X 30MM,10025262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AMPLIA MRI QUAD CRT-D SYSTEM X_AMPLIAMRIQDCRTMMQM,10025324,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,70887.00,21266.10,27504.16,60253.95,,34734.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29772.54,,,percent of total billed charges,,Paid in addition to inpatient services ,27504.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30126.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53165.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35443.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60253.95,,,percent of total billed charges,,,31899.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPLIA MRI QUAD CRT-D SYSTEM X_AMPLIAMRIQDCRTMMQM,10025324,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,70887.00,21266.10,29772.54,60253.95,,34734.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29772.54,,,percent of total billed charges,,Paid in addition to outpatient services ,35755.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30126.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53165.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35443.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53165.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60253.95,,,percent of total billed charges,,,32608.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ATTAIN MPX SRVLV 50CM,10025325,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1233.00,369.90,524.02,1048.05,,761.99,,,percent of total billed charges,,,,,,,,service not payable,601.70,,,percent of total billed charges,,,621.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,524.02,,,percent of total billed charges,,,,,,,,,924.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,616.5,,,percent of total billed charges,,,,,,,,service not payable,924.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1048.05,,,percent of total billed charges,,,567.18,,,percent of total billed charges,,,,,,,,,801.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,801.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BREAST INSPIRA SRX 525ML X_SRX-525 X_ALLER,10025366,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BREAST INSPIRA SRX 525ML X_SRX-525 X_ALLER,10025366,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BODY EPIPH POROCOAT SZ14 135D,10025367,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BODY EPIPH POROCOAT SZ14 135D,10025367,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 4X32MM,10027101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2566.00,769.80,995.61,2181.10,,,,,,,,,,,,,,,,,,,,995.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.10,,,percent of total billed charges,,,1154.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 4X32MM,10027101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2566.00,769.80,1090.55,2181.10,,,,,,,,,,,,,service not payable,,,,,,,1294.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2181.10,,,percent of total billed charges,,,1180.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KWIRE KIRSCHNER NON-TH 1.2MM,10027104,CDM,0272,RC,C1713,HCPCS,,,,,,outpatient,facility,,,351.00,105.30,149.18,298.35,,216.92,,,percent of total billed charges,,,,,,,,service not payable,171.29,,,percent of total billed charges,,,177.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,149.18,,,percent of total billed charges,,,,,,,,,263.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,175.5,,,percent of total billed charges,,,,,,,,service not payable,263.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,298.35,,,percent of total billed charges,,,161.46,,,percent of total billed charges,,,,,,,,,228.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,228.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CRVD 5.5X95MM X_124.695 X_GLOBUS,10027105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CRVD 5.5X95MM X_124.695 X_GLOBUS,10027105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER TLIF LG 11MM X_368.331 X_GLOBUS,10027106,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13113.00,3933.90,5087.84,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5087.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,,5900.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER TLIF LG 11MM X_368.331 X_GLOBUS,10027106,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5507.46,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T10 FT 3.5X36MM X_657436 X_STRYKER ORTHOPAED,10027107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,715.00,214.50,277.42,607.75,,,,,,,,,,,,,,,,,,,,277.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.75,,,percent of total billed charges,,,321.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T10 FT 3.5X36MM X_657436 X_STRYKER ORTHOPAED,10027107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,,,,,,,,,,,,service not payable,,,,,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T10 FT 3.5X34MM X_657434 X_STRYKER ORTHOPAED,10027108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,715.00,214.50,277.42,607.75,,,,,,,,,,,,,,,,,,,,277.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.75,,,percent of total billed charges,,,321.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T10 FT 3.5X34MM X_657434 X_STRYKER ORTHOPAED,10027108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,,,,,,,,,,,,service not payable,,,,,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T10 FT 3.5X34MM X_657334 X_STRYKER ORTH,10027109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1361.00,408.30,528.07,1156.85,,,,,,,,,,,,,,,,,,,,528.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.85,,,percent of total billed charges,,,612.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T10 FT 3.5X34MM X_657334 X_STRYKER ORTH,10027109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1361.00,408.30,578.42,1156.85,,,,,,,,,,,,,service not payable,,,,,,,686.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.85,,,percent of total billed charges,,,626.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T10 FT 3.5X32MM X_657332 X_STRYKER ORTH,10027110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1361.00,408.30,528.07,1156.85,,,,,,,,,,,,,,,,,,,,528.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.85,,,percent of total billed charges,,,612.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T10 FT 3.5X32MM X_657332 X_STRYKER ORTH,10027110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1361.00,408.30,578.42,1156.85,,,,,,,,,,,,,service not payable,,,,,,,686.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.85,,,percent of total billed charges,,,626.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE STND CALC SM X_40-10112 X_STRYKER ORTHOPAEDI,10027111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2683.00,804.90,1041.00,2280.55,,,,,,,,,,,,,,,,,,,,1041.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2012.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2280.55,,,percent of total billed charges,,,1207.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE STND CALC SM X_40-10112 X_STRYKER ORTHOPAEDI,10027111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2683.00,804.90,1140.27,2280.55,,,,,,,,,,,,,service not payable,,,,,,,1353.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1140.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2012.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2012.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2280.55,,,percent of total billed charges,,,1234.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T10 FT 3.4X38MM X_657438 X_STRYKER ORTHOPAED,10027112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,715.00,214.50,277.42,607.75,,,,,,,,,,,,,,,,,,,,277.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.75,,,percent of total billed charges,,,321.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T10 FT 3.4X38MM X_657438 X_STRYKER ORTHOPAED,10027112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,,,,,,,,,,,,service not payable,,,,,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE CNC CHP 5ML 1.7-10MM,10027115,CDM,0278,RC,C9362,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE CNC CHP 5ML 1.7-10MM,10027115,CDM,0278,RC,C9362,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE CNC CHP 5ML 1.7-10MM,10027115,CDM,0278,RC,C9362,HCPCS,455,EAPG,,,,outpatient,facility,,,766.00,229.80,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL LONG TI LT 10X400X125D,10027430,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5995.00,1798.50,2326.06,5095.75,,2937.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2517.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2326.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2547.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4496.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2997.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5095.75,,,percent of total billed charges,,,2697.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL LONG TI LT 10X400X125D,10027430,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5995.00,1798.50,2517.90,5095.75,,2937.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2517.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3023.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2547.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4496.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2997.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4496.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5095.75,,,percent of total billed charges,,,2757.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ICD EVERA MRI S DR X_DDMC3D1 X_MEDTRONIC,10027431,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,35680.00,10704.00,13843.84,30328.0,,17483.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14985.60,,,percent of total billed charges,,Paid in addition to inpatient services ,13843.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26760.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17840.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30328.0,,,percent of total billed charges,,,16056.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ICD EVERA MRI S DR X_DDMC3D1 X_MEDTRONIC,10027431,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,35680.00,10704.00,14985.60,30328.0,,17483.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14985.60,,,percent of total billed charges,,Paid in addition to outpatient services ,17996.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26760.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,17840.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26760.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,30328.0,,,percent of total billed charges,,,16412.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHAMBER 13MM 10.5,10027432,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHAMBER 13MM 10.5,10027432,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4X28MM,10027440,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4X28MM,10027440,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ1 13MM X_5531-G-113 X_STRY,10027441,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ1 13MM X_5531-G-113 X_STRY,10027441,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ1 11MM X_5531-G-111 X_STRY,10027442,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ1 11MM X_5531-G-111 X_STRY,10027442,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ3 13MM X_5537-G-313 X_STRYKER ORTH,10027443,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ3 13MM X_5537-G-313 X_STRYKER ORTH,10027443,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FLUTED 14X150MM X_5566-S-014 X_STRYKER ORTHOP,10027444,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4080.00,1224.00,1583.04,3468.0,,,,,,,,,,,,,,,,,,,,1583.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1734.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3060.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2040.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3468.0,,,percent of total billed charges,,,1836.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FLUTED 14X150MM X_5566-S-014 X_STRYKER ORTHOP,10027444,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4080.00,1224.00,1734.0,3468.0,,,,,,,,,,,,,service not payable,,,,,,,2057.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1734.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3060.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2040.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3060.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3468.0,,,percent of total billed charges,,,1876.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 5.5X35MM X_124.453 X_GLOBUS,10027445,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5.5X35MM X_124.453 X_GLOBUS,10027445,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM REDAPT SZ21 240MM X_71354728 X_SMITH NEPH,10027447,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24792.00,7437.60,9619.30,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9619.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21073.20,,,percent of total billed charges,,,11156.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM REDAPT SZ21 240MM X_71354728 X_SMITH NEPH,10027447,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24792.00,7437.60,10412.64,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12505.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21073.20,,,percent of total billed charges,,,11404.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS16.5 D X_PCB00-16.5 X_ABBOTT,10027448,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS16.5 D X_PCB00-16.5 X_ABBOTT,10027448,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS14.0 D X_PCB00-14.0 X_ABBOTT,10027449,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS14.0 D X_PCB00-14.0 X_ABBOTT,10027449,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SPEED 25X20X20MM,10027451,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6625.00,1987.50,2570.5,5631.25,,3246.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2782.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2570.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2815.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4968.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3312.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5631.25,,,percent of total billed charges,,,2981.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SPEED 25X20X20MM,10027451,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6625.00,1987.50,2782.5,5631.25,,3246.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2782.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3341.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2815.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4968.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3312.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4968.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5631.25,,,percent of total billed charges,,,3047.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSEFORCE STAPLE KIT 10X10 X_FFNS1010 X_WRI,10027559,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4850.00,1455.00,1881.8,4122.5,,,,,,,,,,,,,,,,,,,,1881.8,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2061.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4122.5,,,percent of total billed charges,,,2182.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSEFORCE STAPLE KIT 10X10 X_FFNS1010 X_WRI,10027559,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4850.00,1455.00,2061.25,4122.5,,,,,,,,,,,,,service not payable,,,,,,,2446.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2061.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3637.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3637.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4122.5,,,percent of total billed charges,,,2231.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 22FR 22X22X150MM X_VAFM2222C150TU X_ME,10027560,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 22FR 22X22X150MM X_VAFM2222C150TU X_ME,10027560,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 22FR 24X24X150MM X_VAFM2424C150TU X_ME,10027561,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 22FR 24X24X150MM X_VAFM2424C150TU X_ME,10027561,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 22FR 26X26X150MM X_VAFM2626C150TU X_ME,10027562,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 22FR 26X26X150MM X_VAFM2626C150TU X_ME,10027562,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 22FR 28X28X150MM X_VAFM2828C150TU X_ME,10027563,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 22FR 28X28X150MM X_VAFM2828C150TU X_ME,10027563,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 22FR 30X30X150MM X_VAFM3030C150TU X_ME,10027564,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 22FR 30X30X150MM X_VAFM3030C150TU X_ME,10027564,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC X_VAMF3232C150TU X_MEDTRONIC,10027565,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC X_VAMF3232C150TU X_MEDTRONIC,10027565,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER GUIDE LNCH 7F 90CM X_LA7AL75SHD X_MEDTRON,10027566,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CRAGG MCNAMARA INFUSION 135X40CM 5FR X_41059-,10027567,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,354.73,,,percent of total billed charges,,,,,,,,service not payable,280.11,,,percent of total billed charges,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,373.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,373.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Paravertebral Block (PVB) thoracic single inject,10027624,CDM,0360,RC,64461,CPT,,,,,,outpatient,facility,,,1803.00,540.90,829.38,2912.34,,1803.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,909.43,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1352.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1352.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1532.55,,,percent of total billed charges,,,829.38,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Paravertebral Block (PVB) thoracic single inject,10027624,CDM,0360,RC,64461,CPT,05442,APC,,,,outpatient,facility,,,1803.00,540.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Paravertebral Block (PVB) thoracic single inject,10027624,CDM,0360,RC,64461,CPT,53,EAPG,,,,outpatient,facility,,,1803.00,540.90,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ALLOGRAFT GRACILIS TENDON X_26217000 X_ALLOSOURCE,10029098,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,9059.00,2717.70,3514.89,7700.15,,4438.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3804.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3514.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3850.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6794.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4529.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7700.15,,,percent of total billed charges,,,4076.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT GRACILIS TENDON X_26217000 X_ALLOSOURCE,10029098,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,9059.00,2717.70,3804.78,7700.15,,4438.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3804.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4569.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3850.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6794.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4529.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6794.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7700.15,,,percent of total billed charges,,,4167.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 350ML,10029102,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,8224.00,2467.20,3190.91,6990.40,,4029.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3454.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3190.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3495.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4112.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6990.40,,,percent of total billed charges,,,3700.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 350ML,10029102,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,8224.00,2467.20,3454.08,6990.40,,4029.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3454.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4148.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3495.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4112.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6168.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6990.40,,,percent of total billed charges,,,3783.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 455ML,10029103,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,8224.00,2467.20,3190.91,6990.40,,4029.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3454.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3190.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3495.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4112.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6990.40,,,percent of total billed charges,,,3700.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 455ML,10029103,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,8224.00,2467.20,3454.08,6990.40,,4029.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3454.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4148.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3495.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4112.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6168.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6990.40,,,percent of total billed charges,,,3783.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAR 4.6X12MM X_171.012 X_GLOBUS,10032106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAR 4.6X12MM X_171.012 X_GLOBUS,10032106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ASNIS CANN 605X55MM X_606055S X_STRYKER ORTH,10032107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ASNIS CANN 605X55MM X_606055S X_STRYKER ORTH,10032107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 6.7X55MM X_AR-8967-2855 X_ARTHREX INC,10032109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 6.7X55MM X_AR-8967-2855 X_ARTHREX INC,10032109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACHILLES TENDON BONE BLOCK X_FATB X_LIFENET,10032111,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,7865.00,2359.50,3051.62,6685.25,,3853.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3303.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3051.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3342.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5898.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3932.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6685.25,,,percent of total billed charges,,,3539.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACHILLES TENDON BONE BLOCK X_FATB X_LIFENET,10032111,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,7865.00,2359.50,3303.30,6685.25,,3853.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3303.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3967.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3342.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5898.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3932.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5898.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6685.25,,,percent of total billed charges,,,3617.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TO ROD CPLNG MRI 5X8X11MM X_4922-1-020 X_STRYK,10032122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2421.00,726.30,939.35,2057.85,,,,,,,,,,,,,,,,,,,,939.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1028.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1815.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1210.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2057.85,,,percent of total billed charges,,,1089.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TO ROD CPLNG MRI 5X8X11MM X_4922-1-020 X_STRYK,10032122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2421.00,726.30,1028.92,2057.85,,,,,,,,,,,,,service not payable,,,,,,,1221.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1028.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1815.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1210.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1815.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2057.85,,,percent of total billed charges,,,1113.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF APEX S/D 50 THD 5X200 X_5018-6-200 X_STRY,10032123,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,529.00,158.70,205.25,449.65,,,,,,,,,,,,,,,,,,,,205.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,396.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,264.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,449.65,,,percent of total billed charges,,,238.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF APEX S/D 50 THD 5X200 X_5018-6-200 X_STRY,10032123,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,529.00,158.70,224.82,449.65,,,,,,,,,,,,,service not payable,,,,,,,266.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,224.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,396.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,264.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,396.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,449.65,,,percent of total billed charges,,,243.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ZELANTE DVT 8FX105CM,10032218,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,9787.00,2936.10,4159.48,8318.95,,6048.37,,,percent of total billed charges,,,,,,,,service not payable,4776.06,,,percent of total billed charges,,,4936.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4159.48,,,percent of total billed charges,,,,,,,,,7340.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4893.5,,,percent of total billed charges,,,,,,,,service not payable,7340.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8318.95,,,percent of total billed charges,,,4502.02,,,percent of total billed charges,,,,,,,,,6361.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6361.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT WALL 14X60MM 10FR 100CM,10032219,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3878.00,1163.40,1504.66,3296.30,,,,,,,,,,,,,,,,,,,,1504.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1648.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2908.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1939.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3296.30,,,percent of total billed charges,,,1745.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT WALL 14X60MM 10FR 100CM,10032219,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3878.00,1163.40,1648.15,3296.30,,,,,,,,,,,,,service not payable,,,,,,,1956.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1648.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2908.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1939.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2908.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3296.30,,,percent of total billed charges,,,1783.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT WALL 16X60MM 10FR 100CM,10032220,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3878.00,1163.40,1504.66,3296.30,,,,,,,,,,,,,,,,,,,,1504.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1648.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2908.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1939.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3296.30,,,percent of total billed charges,,,1745.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT WALL 16X60MM 10FR 100CM,10032220,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3878.00,1163.40,1648.15,3296.30,,,,,,,,,,,,,service not payable,,,,,,,1956.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1648.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2908.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1939.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2908.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3296.30,,,percent of total billed charges,,,1783.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH H1 5F 0.035X130CM,10032221,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH JB1 5F 0.035X130CM,10032222,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VERTEBRAL 5F 0.035X130CM,10032223,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 1.6MM X_80-0992 X_ACUMED,10032224,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,157.00,47.10,66.72,133.45,,97.03,,,percent of total billed charges,,,,,,,,service not payable,76.62,,,percent of total billed charges,,,79.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,66.72,,,percent of total billed charges,,,,,,,,,117.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,78.5,,,percent of total billed charges,,,,,,,,service not payable,117.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,133.45,,,percent of total billed charges,,,72.22,,,percent of total billed charges,,,,,,,,,102.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,102.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Soft Tissue Loc 1st Lesion,10032225,CDM,0360,RC,10035,CPT,,,,,,outpatient,facility,,,1707.00,512.10,785.22,3666.78,,1707.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,861.01,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1450.95,,,percent of total billed charges,,,785.22,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Soft Tissue Loc 1st Lesion,10032225,CDM,0360,RC,10035,CPT,05071,APC,,,,outpatient,facility,,,1707.00,512.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Soft Tissue Loc 1st Lesion,10032225,CDM,0360,RC,10035,CPT,4,EAPG,,,,outpatient,facility,,,1707.00,512.10,1546.90,3698.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3698.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3143.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1546.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1701.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Soft Tissue Loc 1st Lesion,10032226,CDM,0360,RC,10035,CPT,,,,,,outpatient,facility,,,1707.00,512.10,785.22,3666.78,,1707.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,861.01,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1450.95,,,percent of total billed charges,,,785.22,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Soft Tissue Loc 1st Lesion,10032226,CDM,0360,RC,10035,CPT,05071,APC,,,,outpatient,facility,,,1707.00,512.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Soft Tissue Loc 1st Lesion,10032226,CDM,0360,RC,10035,CPT,4,EAPG,,,,outpatient,facility,,,1707.00,512.10,1546.90,3698.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3698.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3143.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1546.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1701.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Unlisted Code biliary tract,10032298,CDM,0750,RC,47999,CPT,,,,,,outpatient,facility,,,4004.00,1201.20,1841.84,5463.36,,4004.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,2019.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3003.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3003.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3403.40,,,percent of total billed charges,,,1841.84,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Unlisted Code biliary tract,10032298,CDM,0750,RC,47999,CPT,05301,APC,,,,outpatient,facility,,,4004.00,1201.20,862.39,2064.98,,,,,,,,899.09,,,fee schedule,,,,,,,,,,,,,,,1891.38,,,fee schedule,,,862.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",917.07,,,fee schedule,,,2064.98,,,fee schedule,,,,,,,,,899.09,,,fee schedule,,,,,,,,,,,,,,,1863.97,,,fee schedule,,,,,,,,,899.09,,,fee schedule,,,862.39,,,fee schedule,,,917.07,,,fee schedule,,,,,,,,,899.09,,,fee schedule,,,,,,,,,862.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",917.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,899.09,,,fee schedule,,,,,,,,,,,,,,,899.09,,,fee schedule,,,,,,,,,908.05,,,fee schedule,,,,,,,,
END-Unlisted Code biliary tract,10032298,CDM,0750,RC,47999,CPT,151,EAPG,,,,outpatient,facility,,,4004.00,1201.20,2665.38,8838.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8838.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7512.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3222.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3222.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3222.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2665.38,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2931.92,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM FEM REDAPT SZ15 240MM X_71354722 X_SMITH NEPH,10032333,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24792.00,7437.60,9619.30,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9619.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21073.20,,,percent of total billed charges,,,11156.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM REDAPT SZ15 240MM X_71354722 X_SMITH NEPH,10032333,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24792.00,7437.60,10412.64,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12505.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21073.20,,,percent of total billed charges,,,11404.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COLLAR GLBL UNI SZ40,10032334,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAR GLBL UNI SZ40,10032334,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD GLBL UNITE 40X15 STD,10032358,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLBL UNITE 40X15 STD,10032358,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER PNCL MAR 4 36X60MM,10032359,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER PNCL MAR 4 36X60MM,10032359,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CMNT HIP 35X130MM SZ7 X_6098-0735 X_STRYKER,10032360,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CMNT HIP 35X130MM SZ7 X_6098-0735 X_STRYKER,10032360,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U8 3X10X150 X_U8150310 X_BARD,10032361,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1012.00,303.60,430.10,860.20,,625.42,,,percent of total billed charges,,,,,,,,service not payable,493.86,,,percent of total billed charges,,,510.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,430.10,,,percent of total billed charges,,,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,506.0,,,percent of total billed charges,,,,,,,,service not payable,759.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,860.20,,,percent of total billed charges,,,465.52,,,percent of total billed charges,,,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET NEUT 28X50MM 4,10032362,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15600.00,4680.00,6052.80,13260.0,,7644.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6552.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6052.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6630.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11700.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7800.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13260.0,,,percent of total billed charges,,,7020.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET NEUT 28X50MM 4,10032362,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15600.00,4680.00,6552.0,13260.0,,7644.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6552.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7868.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6630.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11700.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7800.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11700.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13260.0,,,percent of total billed charges,,,7176.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ5-6 13MM X_71453286 X_SMITH NEP,10032429,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ5-6 13MM X_71453286 X_SMITH NEP,10032429,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cytomegalovirus Antibody IgM,10032497,CDM,0300,RC,86645,CPT,,,,,,outpatient,facility,,,152.00,45.60,16.01,129.20,,71.60,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.51,,,fee schedule,,,53.43,,,fee schedule,,,35.14,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,34.88,,,fee schedule,,,16.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.84,,,fee schedule,,,38.08,,,fee schedule,,,,,,,,,16.51,,,fee schedule,,,,,,,,,21.48,,,fee schedule,,,34.37,,,fee schedule,,,114.0,,,percent of total billed charges,,,16.51,,,fee schedule,,,16.01,,,fee schedule,,,16.84,,,fee schedule,,,25.26,,,fee schedule,,,16.51,,,fee schedule,,,114.0,,,percent of total billed charges,,,,,,,,,16.84,,,fee schedule,,,,,,,,,129.20,,,percent of total billed charges,,,69.92,,,percent of total billed charges,,,,,,,,,18.54,,,fee schedule,,,16.51,,,fee schedule,,,,,,,,,16.34,,,fee schedule,,,16.51,,,fee schedule,,,,,,,,,16.68,,,fee schedule,,,,,,,,
Cytomegalovirus Antibody IgM,10032497,CDM,0300,RC,86645,CPT,394,EAPG,,,,outpatient,facility,,,152.00,45.60,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Cytomegalovirus Antibody IgG,10032498,CDM,0300,RC,86644,CPT,,,,,,outpatient,facility,,,130.00,39.00,13.67,110.5,,61.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.1,,,fee schedule,,,45.62,,,fee schedule,,,30.01,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,29.79,,,fee schedule,,,13.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.38,,,fee schedule,,,32.52,,,fee schedule,,,,,,,,,14.1,,,fee schedule,,,,,,,,,18.53,,,fee schedule,,,29.36,,,fee schedule,,,97.5,,,percent of total billed charges,,,14.1,,,fee schedule,,,13.67,,,fee schedule,,,14.38,,,fee schedule,,,21.80,,,fee schedule,,,14.1,,,fee schedule,,,97.5,,,percent of total billed charges,,,,,,,,,14.38,,,fee schedule,,,,,,,,,110.5,,,percent of total billed charges,,,59.80,,,percent of total billed charges,,,,,,,,,15.83,,,fee schedule,,,14.1,,,fee schedule,,,,,,,,,13.96,,,fee schedule,,,14.1,,,fee schedule,,,,,,,,,14.24,,,fee schedule,,,,,,,,
Cytomegalovirus Antibody IgG,10032498,CDM,0300,RC,86644,CPT,394,EAPG,,,,outpatient,facility,,,130.00,39.00,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Cytomegalovirus Antibodies IgG and IgM,10032499,CDM,0300,RC,86644,CPT,,,,,,outpatient,facility,,,130.00,39.00,13.67,110.5,,61.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.1,,,fee schedule,,,45.62,,,fee schedule,,,30.01,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,29.79,,,fee schedule,,,13.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.38,,,fee schedule,,,32.52,,,fee schedule,,,,,,,,,14.1,,,fee schedule,,,,,,,,,18.53,,,fee schedule,,,29.36,,,fee schedule,,,97.5,,,percent of total billed charges,,,14.1,,,fee schedule,,,13.67,,,fee schedule,,,14.38,,,fee schedule,,,21.80,,,fee schedule,,,14.1,,,fee schedule,,,97.5,,,percent of total billed charges,,,,,,,,,14.38,,,fee schedule,,,,,,,,,110.5,,,percent of total billed charges,,,59.80,,,percent of total billed charges,,,,,,,,,15.83,,,fee schedule,,,14.1,,,fee schedule,,,,,,,,,13.96,,,fee schedule,,,14.1,,,fee schedule,,,,,,,,,14.24,,,fee schedule,,,,,,,,
Cytomegalovirus Antibodies IgG and IgM,10032499,CDM,0300,RC,86644,CPT,394,EAPG,,,,outpatient,facility,,,130.00,39.00,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW LP VA TI 2.4X28MM X_AR-8724V-28 X_ARTHREX IN,10032546,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP VA TI 2.4X28MM X_AR-8724V-28 X_ARTHREX IN,10032546,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PRIMATRIX MESHED DISC 14MM,10032551,CDM,0278,RC,Q4110,HCPCS,,,,,,inpatient,facility,,,2651.00,795.30,1028.59,2253.35,,,,,,,,,,,,,,,,,,,,1028.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2253.35,,,percent of total billed charges,,,1192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMATRIX MESHED DISC 14MM,10032551,CDM,0278,RC,Q4110,HCPCS,,,,,,outpatient,facility,,,2651.00,795.30,1126.68,2253.35,,,,,,,,,,,,,service not payable,,,,,,,1337.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2253.35,,,percent of total billed charges,,,1219.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PRIMATRIX MESHED DISC 14MM,10032551,CDM,0278,RC,Q4110,HCPCS,2010,EAPG,,,,outpatient,facility,,,2651.00,795.30,55.60,65.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.41,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,65.41,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PRIMATRIX MESHED 2X2CM,10032552,CDM,0278,RC,Q4110,HCPCS,,,,,,inpatient,facility,,,3051.00,915.30,1183.79,2593.35,,,,,,,,,,,,,,,,,,,,1183.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2288.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1525.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2593.35,,,percent of total billed charges,,,1372.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMATRIX MESHED 2X2CM,10032552,CDM,0278,RC,Q4110,HCPCS,,,,,,outpatient,facility,,,3051.00,915.30,1296.68,2593.35,,,,,,,,,,,,,service not payable,,,,,,,1538.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1296.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2288.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1525.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2288.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2593.35,,,percent of total billed charges,,,1403.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PRIMATRIX MESHED 2X2CM,10032552,CDM,0278,RC,Q4110,HCPCS,2010,EAPG,,,,outpatient,facility,,,3051.00,915.30,55.60,65.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.41,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,65.41,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LEAD PACING BIPOLR RH 5F 110CM,10032553,CDM,0278,RC,C1898,HCPCS,,,,,,inpatient,facility,,,538.00,161.40,208.74,457.30,,,,,,,,,,,,,,,,,,,,208.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,403.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,269.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.30,,,percent of total billed charges,,,242.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACING BIPOLR RH 5F 110CM,10032553,CDM,0278,RC,C1898,HCPCS,,,,,,outpatient,facility,,,538.00,161.40,228.65,457.30,,,,,,,,,,,,,service not payable,,,,,,,271.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,228.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,403.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,269.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,403.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,457.30,,,percent of total billed charges,,,247.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLCKG 3.5X30MM X_657430 X_STRYKER ORTHOPAE,10032556,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,930.00,279.00,360.84,790.5,,,,,,,,,,,,,,,,,,,,360.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLCKG 3.5X30MM X_657430 X_STRYKER ORTHOPAE,10032556,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,,,,,,,,,,,,service not payable,,,,,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAMTS 13 Activity,10032566,CDM,0300,RC,85397,CPT,,,,,,outpatient,facility,,,234.00,70.20,29.32,198.90,,86.56,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,30.24,,,fee schedule,,,64.59,,,fee schedule,,,64.36,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,63.88,,,fee schedule,,,29.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.84,,,fee schedule,,,69.74,,,fee schedule,,,,,,,,,30.24,,,fee schedule,,,,,,,,,39.59,,,fee schedule,,,62.95,,,fee schedule,,,175.5,,,percent of total billed charges,,,30.24,,,fee schedule,,,29.32,,,fee schedule,,,30.84,,,fee schedule,,,46.56,,,fee schedule,,,30.24,,,fee schedule,,,175.5,,,percent of total billed charges,,,,,,,,,30.84,,,fee schedule,,,,,,,,,198.90,,,percent of total billed charges,,,107.64,,,percent of total billed charges,,,,,,,,,33.95,,,fee schedule,,,30.24,,,fee schedule,,,,,,,,,29.93,,,fee schedule,,,30.24,,,fee schedule,,,,,,,,,30.55,,,fee schedule,,,,,,,,
ADAMTS 13 Activity,10032566,CDM,0300,RC,85397,CPT,407,EAPG,,,,outpatient,facility,,,234.00,70.20,29.94,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,29.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,29.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,85.93,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL HUMERAL 9X270MM,10032722,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3923.00,1176.90,1522.12,3334.55,,,,,,,,,,,,,,,,,,,,1522.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1667.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2942.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1961.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3334.55,,,percent of total billed charges,,,1765.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 9X270MM,10032722,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3923.00,1176.90,1667.27,3334.55,,,,,,,,,,,,,service not payable,,,,,,,1978.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1667.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2942.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1961.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2942.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3334.55,,,percent of total billed charges,,,1804.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR MRI SAFE IPG MONTAGE,10032723,CDM,0278,RC,C1822,HCPCS,,,,,,inpatient,facility,,,53435.00,16030.50,20732.78,45419.75,,26183.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22442.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,20732.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22709.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,40076.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26717.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45419.75,,,percent of total billed charges,,,24045.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR MRI SAFE IPG MONTAGE,10032723,CDM,0278,RC,C1822,HCPCS,,,,,,outpatient,facility,,,53435.00,16030.50,22442.70,45419.75,,26183.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22442.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,26952.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,22709.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,40076.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26717.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,40076.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,45419.75,,,percent of total billed charges,,,24580.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR CLIK X MRI SAFE,10032724,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR CLIK X MRI SAFE,10032724,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CRYOPROBE V PROBE5 R-ANG 2.4MM,10032727,CDM,0272,RC,C2618,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,2026.42,,,percent of total billed charges,,,,,,,,service not payable,1600.15,,,percent of total billed charges,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON DRUG COATED PTA CATH 5F 4X150MM X_LX351304,10032728,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2160.28,4320.55,,3141.29,,,percent of total billed charges,,,,,,,,service not payable,2480.5,,,percent of total billed charges,,,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2541.5,,,percent of total billed charges,,,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,3303.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3303.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST SALINE HP 350ML,10032729,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST SALINE HP 350ML,10032729,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.5X16MM,10032731,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.5X16MM,10032731,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.5X20MM,10032732,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.5X20MM,10032732,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.5X28MM,10032733,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.5X28MM,10032733,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.0X32MM,10032734,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.0X32MM,10032734,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.5X16MM,10032735,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.5X16MM,10032735,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3X16MM,10032736,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3X16MM,10032736,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.5X16MM,10032737,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.5X16MM,10032737,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4X16MM,10032738,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4X16MM,10032738,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.5X20MM,10032739,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.5X20MM,10032739,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3X20MM,10032740,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3X20MM,10032740,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.5X20MM,10032741,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.5X20MM,10032741,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4X20MM,10032742,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4X20MM,10032742,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.5X24MM,10032743,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.5X24MM,10032743,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3X24MM,10032744,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3X24MM,10032744,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.5X24MM,10032745,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.5X24MM,10032745,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4X24MM,10032746,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4X24MM,10032746,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.5X24MM,10032747,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.5X24MM,10032747,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.5X28MM,10032748,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.5X28MM,10032748,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3X28MM,10032749,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3X28MM,10032749,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.5X28MM,10032750,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.5X28MM,10032750,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cytomegalovirus Antibodies IgM,10032992,CDM,0300,RC,86645,CPT,,,,,,outpatient,facility,,,152.00,45.60,16.01,129.20,,71.60,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.51,,,fee schedule,,,53.43,,,fee schedule,,,35.14,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,34.88,,,fee schedule,,,16.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.84,,,fee schedule,,,38.08,,,fee schedule,,,,,,,,,16.51,,,fee schedule,,,,,,,,,21.48,,,fee schedule,,,34.37,,,fee schedule,,,114.0,,,percent of total billed charges,,,16.51,,,fee schedule,,,16.01,,,fee schedule,,,16.84,,,fee schedule,,,25.26,,,fee schedule,,,16.51,,,fee schedule,,,114.0,,,percent of total billed charges,,,,,,,,,16.84,,,fee schedule,,,,,,,,,129.20,,,percent of total billed charges,,,69.92,,,percent of total billed charges,,,,,,,,,18.54,,,fee schedule,,,16.51,,,fee schedule,,,,,,,,,16.34,,,fee schedule,,,16.51,,,fee schedule,,,,,,,,,16.68,,,fee schedule,,,,,,,,
Cytomegalovirus Antibodies IgM,10032992,CDM,0300,RC,86645,CPT,394,EAPG,,,,outpatient,facility,,,152.00,45.60,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE T LP 2.4MM 4H,10033039,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE T LP 2.4MM 4H,10033039,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2.4X14 X_7440-2414N X_SMITH NEPHEW,10033041,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,268.00,80.40,103.98,227.80,,,,,,,,,,,,,,,,,,,,103.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,,120.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2.4X14 X_7440-2414N X_SMITH NEPHEW,10033041,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,268.00,80.40,113.90,227.80,,,,,,,,,,,,,service not payable,,,,,,,135.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,113.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,201.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,134.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,201.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X13MM X_7441-2413N X_SMITH NEPHEW,10033042,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X13MM X_7441-2413N X_SMITH NEPHEW,10033042,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X16MM X_7441-2416N X_SMITH NEPHEW,10033043,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X16MM X_7441-2416N X_SMITH NEPHEW,10033043,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TEMPLATES LT X_71158017 X_SMITH NEPHEW,10033044,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,58.00,17.40,22.50,49.30,,,,,,,,,,,,,,,,,,,,22.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.30,,,percent of total billed charges,,,26.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TEMPLATES LT X_71158017 X_SMITH NEPHEW,10033044,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,58.00,17.40,24.65,49.30,,,,,,,,,,,,,service not payable,,,,,,,29.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,43.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,43.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,49.30,,,percent of total billed charges,,,26.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE WIDE 4H LT X_71158020 X_SMITH NEPHEW,10033045,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4193.00,1257.90,1626.88,3564.05,,,,,,,,,,,,,,,,,,,,1626.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1782.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3144.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2096.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3564.05,,,percent of total billed charges,,,1886.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE WIDE 4H LT X_71158020 X_SMITH NEPHEW,10033045,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4193.00,1257.90,1782.02,3564.05,,,,,,,,,,,,,service not payable,,,,,,,2114.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1782.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3144.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2096.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3144.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3564.05,,,percent of total billed charges,,,1928.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 8.5MMX24CM X_71771024 X_SMITH NEPHEW,10033046,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4291.00,1287.30,1664.91,3647.35,,,,,,,,,,,,,,,,,,,,1664.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1823.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3218.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2145.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3647.35,,,percent of total billed charges,,,1930.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 8.5MMX24CM X_71771024 X_SMITH NEPHEW,10033046,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4291.00,1287.30,1823.68,3647.35,,,,,,,,,,,,,service not payable,,,,,,,2164.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1823.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3218.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2145.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3218.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3647.35,,,percent of total billed charges,,,1973.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE FEED TG JEJUN MIC 16FR,10033047,CDM,0272,RC,B4087,HCPCS,,,,,,outpatient,facility,,,1321.00,396.30,37.03,1122.85,,816.38,,,percent of total billed charges,,,,,,,,service not payable,644.65,,,percent of total billed charges,,,666.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,660.5,,,fee schedule,,,37.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,660.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,561.42,,,percent of total billed charges,,,,,,,,,990.75,,,percent of total billed charges,,,,,,,,service not payable,37.03,,,fee schedule,,,,,,,,,660.5,,,percent of total billed charges,,,,,,,,service not payable,990.75,,,percent of total billed charges,,,37.03,,,fee schedule,,,594.45,,,fee schedule,,,,,,,,,1122.85,,,percent of total billed charges,,,607.66,,,percent of total billed charges,,,,,,,,,858.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,858.65,,,percent of total billed charges,,,660.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
TUBE FEED TG JEJUN MIC 16FR,10033047,CDM,0272,RC,B4087,HCPCS,498,EAPG,,,,outpatient,facility,,,1321.00,396.30,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH BALLOON PTA 7X60MM 130CM 5FR X_LX351307605F X,10033051,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,2533.18,,,percent of total billed charges,,,,,,,,service not payable,2000.31,,,percent of total billed charges,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RADIAL HEAD SYSTEM 20MM X_TR-H200R-S X_ACUMED,10033052,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8809.00,2642.70,3417.89,7487.65,,4316.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3699.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3417.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3743.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6606.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4404.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7487.65,,,percent of total billed charges,,,3964.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RADIAL HEAD SYSTEM 20MM X_TR-H200R-S X_ACUMED,10033052,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8809.00,2642.70,3699.78,7487.65,,4316.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3699.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4443.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3743.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6606.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4404.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6606.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7487.65,,,percent of total billed charges,,,4052.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE-S HALLU-LOCK SZ2 5DEG LT X_290650SND X_INTEG,10033053,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5619.00,1685.70,2180.17,4776.15,,2753.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2359.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2180.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2388.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4214.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2809.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4776.15,,,percent of total billed charges,,,2528.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE-S HALLU-LOCK SZ2 5DEG LT X_290650SND X_INTEG,10033053,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5619.00,1685.70,2359.98,4776.15,,2753.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2359.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2834.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2388.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4214.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2809.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4214.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4776.15,,,percent of total billed charges,,,2584.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BARRIER OSTOMY 2PC 2.75X1.5IN X_14804 X_351675,10033108,CDM,0272,RC,A4373,HCPCS,,,,,,outpatient,facility,,,63.00,18.90,26.77,53.55,,38.93,,,percent of total billed charges,,,,,,,,service not payable,30.74,,,percent of total billed charges,,,31.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,26.77,,,percent of total billed charges,,,,,,,,,47.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.5,,,percent of total billed charges,,,,,,,,service not payable,47.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,53.55,,,percent of total billed charges,,,28.98,,,percent of total billed charges,,,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KB Pseudomonas aeruginosa,10033115,CDM,0300,RC,87184,CPT,,,,,,outpatient,facility,,,86.00,25.80,7.11,73.10,,29.32,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.33,,,fee schedule,,,21.88,,,fee schedule,,,15.6,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,15.48,,,fee schedule,,,7.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.48,,,fee schedule,,,16.90,,,fee schedule,,,,,,,,,7.33,,,fee schedule,,,,,,,,,9.69,,,fee schedule,,,15.26,,,fee schedule,,,64.5,,,percent of total billed charges,,,7.33,,,fee schedule,,,7.11,,,fee schedule,,,7.48,,,fee schedule,,,11.4,,,fee schedule,,,7.33,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,7.48,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,8.23,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.26,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.40,,,fee schedule,,,,,,,,
KB Pseudomonas aeruginosa,10033115,CDM,0300,RC,87184,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPLINT WRIST THMB BK RT SM 8IN X_A1425205 X_351301,10033129,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK RT SM 8IN X_A1425205 X_351301,10033129,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK RT MD 8IN X_A125206 X_351302,10033130,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK RT MD 8IN X_A125206 X_351302,10033130,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK RT LG 8IN X_A125207 X_351303,10033131,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK RT LG 8IN X_A125207 X_351303,10033131,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK RT XL 8IN X_A125208 X_351304,10033132,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK RT XL 8IN X_A125208 X_351304,10033132,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK LT SM 8IN X_A125105 X_351305,10033133,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK LT SM 8IN X_A125105 X_351305,10033133,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK LT MD 8IN X_A125106 X_351306,10033134,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK LT MD 8IN X_A125106 X_351306,10033134,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK LT LG 8IN X_A125107 X_351307,10033135,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK LT LG 8IN X_A125107 X_351307,10033135,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
SPLINT WRIST THMB BK LT XL 8IN X_A125108 X_351308,10033136,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,50.00,15.00,19.40,42.5,,,,,,,,,,,,,,,,,,,,19.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK LT XL 8IN X_A125108 X_351308,10033136,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,113.00,,,,,,,,49.20,,,fee schedule,,,,,,,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,103.50,,,fee schedule,,,50.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.18,,,fee schedule,,,113.00,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.0,,,fee schedule,,,37.5,,,percent of total billed charges,,,49.20,,,fee schedule,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,25.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.20,,,fee schedule,,,37.5,,,percent of total billed charges,,,50.0,,,fee schedule,,,50.18,,,fee schedule,,,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,,,,,,,49.20,,,fee schedule,,,,,,,,,49.20,,,fee schedule,,,,,,,,
Dengue Fever Virus Antibodies IgG,10033177,CDM,0300,RC,86790,CPT,,,,,,outpatient,facility,,,77.00,23.10,12.24,65.45,,54.74,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.62,,,fee schedule,,,40.84,,,fee schedule,,,26.86,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.66,,,fee schedule,,,12.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.87,,,fee schedule,,,29.11,,,fee schedule,,,,,,,,,12.62,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.28,,,fee schedule,,,57.75,,,percent of total billed charges,,,12.62,,,fee schedule,,,12.24,,,fee schedule,,,12.87,,,fee schedule,,,19.32,,,fee schedule,,,12.62,,,fee schedule,,,57.75,,,percent of total billed charges,,,,,,,,,12.87,,,fee schedule,,,,,,,,,65.45,,,percent of total billed charges,,,35.42,,,percent of total billed charges,,,,,,,,,14.17,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.49,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.75,,,fee schedule,,,,,,,,
Dengue Fever Virus Antibodies IgG,10033177,CDM,0300,RC,86790,CPT,394,EAPG,,,,outpatient,facility,,,77.00,23.10,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Dengue Fever Virus Antibodies IgM,10033178,CDM,0300,RC,86790,CPT,,,,,,outpatient,facility,,,78.00,23.40,12.24,66.30,,54.74,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.62,,,fee schedule,,,40.84,,,fee schedule,,,26.86,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.66,,,fee schedule,,,12.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.87,,,fee schedule,,,29.11,,,fee schedule,,,,,,,,,12.62,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.28,,,fee schedule,,,58.5,,,percent of total billed charges,,,12.62,,,fee schedule,,,12.24,,,fee schedule,,,12.87,,,fee schedule,,,19.32,,,fee schedule,,,12.62,,,fee schedule,,,58.5,,,percent of total billed charges,,,,,,,,,12.87,,,fee schedule,,,,,,,,,66.30,,,percent of total billed charges,,,35.88,,,percent of total billed charges,,,,,,,,,14.17,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.49,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.75,,,fee schedule,,,,,,,,
Dengue Fever Virus Antibodies IgM,10033178,CDM,0300,RC,86790,CPT,394,EAPG,,,,outpatient,facility,,,78.00,23.40,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Dengue Fever Virus Antibodies IgG and IgM,10033179,CDM,0300,RC,86790,CPT,,,,,,outpatient,facility,,,58.00,17.40,12.24,54.74,,54.74,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.62,,,fee schedule,,,40.84,,,fee schedule,,,26.86,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.66,,,fee schedule,,,12.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.87,,,fee schedule,,,29.11,,,fee schedule,,,,,,,,,12.62,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.28,,,fee schedule,,,43.5,,,percent of total billed charges,,,12.62,,,fee schedule,,,12.24,,,fee schedule,,,12.87,,,fee schedule,,,19.32,,,fee schedule,,,12.62,,,fee schedule,,,43.5,,,percent of total billed charges,,,,,,,,,12.87,,,fee schedule,,,,,,,,,49.30,,,percent of total billed charges,,,26.68,,,percent of total billed charges,,,,,,,,,14.17,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.49,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.75,,,fee schedule,,,,,,,,
Dengue Fever Virus Antibodies IgG and IgM,10033179,CDM,0300,RC,86790,CPT,394,EAPG,,,,outpatient,facility,,,58.00,17.40,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LENS 4.0D X_MN60MA-4.0 X_ALCON LAB INC,10033184,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2399.00,719.70,930.81,2039.15,,,,,,,,,,,,,,,,,,,,930.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1019.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1799.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1199.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2039.15,,,percent of total billed charges,,,1079.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 4.0D X_MN60MA-4.0 X_ALCON LAB INC,10033184,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2399.00,719.70,1019.57,2039.15,,,,,,,,,,,,,service not payable,,,,,,,1210.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1019.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1799.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1199.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1799.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2039.15,,,percent of total billed charges,,,1103.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TABLE INFINITY SZ4 X_33650004 X_WRIGHT MEDICA,10033185,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18361.00,5508.30,7124.07,15606.85,,8996.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7711.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7124.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13770.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15606.85,,,percent of total billed charges,,,8262.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TABLE INFINITY SZ4 X_33650004 X_WRIGHT MEDICA,10033185,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18361.00,5508.30,7711.62,15606.85,,8996.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7711.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9261.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7803.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13770.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13770.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15606.85,,,percent of total billed charges,,,8446.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DOME TALAR INFINITY SZ3,10033186,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,19483.00,5844.90,7559.40,16560.55,,9546.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8182.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7559.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8280.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14612.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9741.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16560.55,,,percent of total billed charges,,,8767.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOME TALAR INFINITY SZ3,10033186,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,19483.00,5844.90,8182.86,16560.55,,9546.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8182.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9827.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8280.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14612.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9741.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14612.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16560.55,,,percent of total billed charges,,,8962.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT POLY ANKLE 9MM SZ3 X_33654309 X_WRIGHT MEDI,10033188,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT POLY ANKLE 9MM SZ3 X_33654309 X_WRIGHT MEDI,10033188,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PARALLEL POST LUMBAR 7MM X_26806442 X_DCI D,10033189,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,8851.00,2655.30,3434.19,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3434.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.35,,,percent of total billed charges,,,3982.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PARALLEL POST LUMBAR 7MM X_26806442 X_DCI D,10033189,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,8851.00,2655.30,3717.42,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4464.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6638.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7523.35,,,percent of total billed charges,,,4071.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 3X16MM,10033191,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 3X16MM,10033191,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 3X20MM,10033192,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2566.00,769.80,995.61,2181.10,,,,,,,,,,,,,,,,,,,,995.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.10,,,percent of total billed charges,,,1154.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 3X20MM,10033192,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2566.00,769.80,1090.55,2181.10,,,,,,,,,,,,,service not payable,,,,,,,1294.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2181.10,,,percent of total billed charges,,,1180.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 3X28MM,10033193,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 3X28MM,10033193,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KWIRE KIRSCHNER NON-TH 1.15MM,10033196,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,351.00,105.30,136.19,298.35,,,,,,,,,,,,,,,,,,,,136.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,263.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,175.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.35,,,percent of total billed charges,,,157.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KWIRE KIRSCHNER NON-TH 1.15MM,10033196,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,351.00,105.30,149.17,298.35,,,,,,,,,,,,,service not payable,,,,,,,177.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,149.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,263.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,175.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,263.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,298.35,,,percent of total billed charges,,,161.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 4.0X30MM X_IH4030 X_STRYKER ORTHOPAEDIC,10033197,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2566.00,769.80,995.61,2181.10,,,,,,,,,,,,,,,,,,,,995.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.10,,,percent of total billed charges,,,1154.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 4.0X30MM X_IH4030 X_STRYKER ORTHOPAEDIC,10033197,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2566.00,769.80,1090.55,2181.10,,,,,,,,,,,,,service not payable,,,,,,,1294.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2181.10,,,percent of total billed charges,,,1180.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL INTERLOCK IDC 18X10X50MM,10033198,CDM,0278,RC,C2628,HCPCS,,,,,,inpatient,facility,,,3964.00,1189.20,1538.03,3369.40,,,,,,,,,,,,,,,,,,,,1538.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1684.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2973.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1982.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3369.40,,,percent of total billed charges,,,1783.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL INTERLOCK IDC 18X10X50MM,10033198,CDM,0278,RC,C2628,HCPCS,,,,,,outpatient,facility,,,3964.00,1189.20,1684.7,3369.40,,,,,,,,,,,,,service not payable,,,,,,,1999.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1684.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2973.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1982.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2973.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3369.40,,,percent of total billed charges,,,1823.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL INTERLOCK IDC 18X14X50MM,10033199,CDM,0278,RC,C2628,HCPCS,,,,,,inpatient,facility,,,3964.00,1189.20,1538.03,3369.40,,,,,,,,,,,,,,,,,,,,1538.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1684.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2973.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1982.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3369.40,,,percent of total billed charges,,,1783.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL INTERLOCK IDC 18X14X50MM,10033199,CDM,0278,RC,C2628,HCPCS,,,,,,outpatient,facility,,,3964.00,1189.20,1684.7,3369.40,,,,,,,,,,,,,service not payable,,,,,,,1999.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1684.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2973.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1982.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2973.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3369.40,,,percent of total billed charges,,,1823.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL INTERLOCK IDC 14X30,10033200,CDM,0278,RC,C2628,HCPCS,,,,,,inpatient,facility,,,3964.00,1189.20,1538.03,3369.40,,,,,,,,,,,,,,,,,,,,1538.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1684.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2973.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1982.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3369.40,,,percent of total billed charges,,,1783.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL INTERLOCK IDC 14X30,10033200,CDM,0278,RC,C2628,HCPCS,,,,,,outpatient,facility,,,3964.00,1189.20,1684.7,3369.40,,,,,,,,,,,,,service not payable,,,,,,,1999.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1684.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2973.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1982.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2973.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3369.40,,,percent of total billed charges,,,1823.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PED BALL TIP NIM 2.3MM X_ DM-9450051 X_NUVAS,10033201,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,738.00,221.40,286.34,627.30,,,,,,,,,,,,,,,,,,,,286.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,332.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PED BALL TIP NIM 2.3MM X_ DM-9450051 X_NUVAS,10033201,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,,,,,,,,,,,,service not payable,,,,,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM UNIV FLTD 75X10MM,10033203,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5550.00,1665.00,2153.40,4717.5,,2719.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2331.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2153.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2358.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4162.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4717.5,,,percent of total billed charges,,,2497.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM UNIV FLTD 75X10MM,10033203,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5550.00,1665.00,2331.0,4717.5,,2719.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2331.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2799.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2358.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4162.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4162.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4717.5,,,percent of total billed charges,,,2553.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SS 16THD 7X30MM X_71127030 X_SMITH NEPH,10033204,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SS 16THD 7X30MM X_71127030 X_SMITH NEPH,10033204,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROTECTOR NERVE 3X15MM,10033205,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,5083.00,1524.90,1972.20,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1972.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4320.55,,,percent of total billed charges,,,2287.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTECTOR NERVE 3X15MM,10033205,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2134.86,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROTECTOR NERVE 3X15MM,10033205,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,5083.00,1524.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NERVE GRAFT ADVANCE 1X50MM X_111250 X_AXOGEN INC,10033206,CDM,0278,RC,C9352,HCPCS,,,,,,inpatient,facility,,,14178.00,4253.40,5501.06,12051.30,,6947.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5954.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5501.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6025.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10633.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7089.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12051.30,,,percent of total billed charges,,,6380.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NERVE GRAFT ADVANCE 1X50MM X_111250 X_AXOGEN INC,10033206,CDM,0278,RC,C9352,HCPCS,,,,,,outpatient,facility,,,14178.00,4253.40,5954.76,12051.30,,6947.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5954.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7151.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6025.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10633.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7089.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10633.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12051.30,,,percent of total billed charges,,,6521.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NERVE GRAFT ADVANCE 1X50MM X_111250 X_AXOGEN INC,10033206,CDM,0278,RC,C9352,HCPCS,455,EAPG,,,,outpatient,facility,,,14178.00,4253.40,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RET AUTOCAPTURE EXPRESSE,10033207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,290.00,87.00,112.52,246.5,,,,,,,,,,,,,,,,,,,,112.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,217.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,,130.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RET AUTOCAPTURE EXPRESSE,10033207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,290.00,87.00,123.25,246.5,,,,,,,,,,,,,service not payable,,,,,,,146.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,217.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,145.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,217.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,246.5,,,percent of total billed charges,,,133.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMUR AS NAR RT CR SZ5 X_NN910Z X_AESCUL,10033209,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMUR AS NAR RT CR SZ5 X_NN910Z X_AESCUL,10033209,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Dengue Fever Virus Ab IgM,10033311,CDM,0300,RC,86790,CPT,,,,,,outpatient,facility,,,51.00,15.30,12.24,51.0,,51.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.62,,,fee schedule,,,40.84,,,fee schedule,,,26.86,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.66,,,fee schedule,,,12.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.87,,,fee schedule,,,29.11,,,fee schedule,,,,,,,,,12.62,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.28,,,fee schedule,,,38.25,,,percent of total billed charges,,,12.62,,,fee schedule,,,12.24,,,fee schedule,,,12.87,,,fee schedule,,,19.32,,,fee schedule,,,12.62,,,fee schedule,,,38.25,,,percent of total billed charges,,,,,,,,,12.87,,,fee schedule,,,,,,,,,43.35,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,14.17,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.49,,,fee schedule,,,12.62,,,fee schedule,,,,,,,,,12.75,,,fee schedule,,,,,,,,
Dengue Fever Virus Ab IgM,10033311,CDM,0300,RC,86790,CPT,394,EAPG,,,,outpatient,facility,,,51.00,15.30,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR HEAILCOIL PK 4.5MM X_72203982 X_SMITH NEPHE,10033490,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR HEAILCOIL PK 4.5MM X_72203982 X_SMITH NEPHE,10033490,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ8 LT X_71423208 X_SMITH NEPHEW,10033491,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ8 LT X_71423208 X_SMITH NEPHEW,10033491,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP SEGMENTAL LPS 40MM,10033492,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6869.00,2060.70,2665.17,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2665.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5838.65,,,percent of total billed charges,,,3091.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP SEGMENTAL LPS 40MM,10033492,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6869.00,2060.70,2884.98,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3464.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5838.65,,,percent of total billed charges,,,3159.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP SEGMENTAL LPS 25MM,10033493,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6869.00,2060.70,2665.17,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2665.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5838.65,,,percent of total billed charges,,,3091.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP SEGMENTAL LPS 25MM,10033493,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6869.00,2060.70,2884.98,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3464.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5838.65,,,percent of total billed charges,,,3159.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TPR CMNT 13X120MM,10033494,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TPR CMNT 13X120MM,10033494,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON DILAT URS 18FR 6MMX10CM X_BURS0610 X_OLYMP,10033495,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1000.00,300.00,425.0,850.0,,618.0,,,percent of total billed charges,,,,,,,,service not payable,488.0,,,percent of total billed charges,,,504.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,425.0,,,percent of total billed charges,,,,,,,,,750.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,500.0,,,percent of total billed charges,,,,,,,,service not payable,750.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,850.0,,,percent of total billed charges,,,460.0,,,percent of total billed charges,,,,,,,,,650.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,650.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PRX HUM HI 3H 80MM RT,10033536,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5531.00,1659.30,2146.03,4701.35,,2710.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2323.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2146.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2350.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4148.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2765.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4701.35,,,percent of total billed charges,,,2488.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PRX HUM HI 3H 80MM RT,10033536,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5531.00,1659.30,2323.02,4701.35,,2710.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2323.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2789.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2350.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4148.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2765.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4148.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4701.35,,,percent of total billed charges,,,2544.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT LK TI ST 3.5X54MM NS,10033537,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,842.00,252.60,326.70,715.70,,,,,,,,,,,,,,,,,,,,326.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.70,,,percent of total billed charges,,,378.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT LK TI ST 3.5X54MM NS,10033537,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,842.00,252.60,357.85,715.70,,,,,,,,,,,,,service not payable,,,,,,,424.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,631.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,715.70,,,percent of total billed charges,,,387.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK MD T15 3.5X24MM,10033538,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK MD T15 3.5X24MM,10033538,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT LP 3.5X24MM,10033539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,345.00,103.50,133.86,293.25,,,,,,,,,,,,,,,,,,,,133.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.25,,,percent of total billed charges,,,155.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT LP 3.5X24MM,10033539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,345.00,103.50,146.62,293.25,,,,,,,,,,,,,service not payable,,,,,,,174.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,258.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,158.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT LP 3.5X26MM,10033540,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,345.00,103.50,133.86,293.25,,,,,,,,,,,,,,,,,,,,133.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.25,,,percent of total billed charges,,,155.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT LP 3.5X26MM,10033540,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,345.00,103.50,146.62,293.25,,,,,,,,,,,,,service not payable,,,,,,,174.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,258.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,158.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT LP 3.5X46MM,10033541,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,345.00,103.50,133.86,293.25,,,,,,,,,,,,,,,,,,,,133.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.25,,,percent of total billed charges,,,155.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT LP 3.5X46MM,10033541,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,345.00,103.50,146.62,293.25,,,,,,,,,,,,,service not payable,,,,,,,174.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,258.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,158.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT LK TI ST 3.5X65MM NS,10033542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,842.00,252.60,326.70,715.70,,,,,,,,,,,,,,,,,,,,326.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.70,,,percent of total billed charges,,,378.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT LK TI ST 3.5X65MM NS,10033542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,842.00,252.60,357.85,715.70,,,,,,,,,,,,,service not payable,,,,,,,424.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,631.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,715.70,,,percent of total billed charges,,,387.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SUPERA 5.5X100 X_S-55-100-120-P6 X_ABBOTT VA,10033600,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9163.00,2748.90,3555.24,7788.55,,4489.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3848.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3555.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3894.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6872.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4581.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7788.55,,,percent of total billed charges,,,4123.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SUPERA 5.5X100 X_S-55-100-120-P6 X_ABBOTT VA,10033600,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9163.00,2748.90,3848.46,7788.55,,4489.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3848.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4621.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3894.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6872.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4581.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6872.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7788.55,,,percent of total billed charges,,,4214.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUBE RANCHO 5H X_103455 X_SMITH NEPHEW,10033601,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1426.00,427.80,553.29,1212.10,,,,,,,,,,,,,,,,,,,,553.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,606.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1069.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1212.10,,,percent of total billed charges,,,641.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUBE RANCHO 5H X_103455 X_SMITH NEPHEW,10033601,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1426.00,427.80,606.05,1212.10,,,,,,,,,,,,,service not payable,,,,,,,719.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,606.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1069.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1069.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1212.10,,,percent of total billed charges,,,655.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE U 155MM X_71071304 X_SMITH NEPHEW,10033602,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5446.00,1633.80,2113.05,4629.10,,2668.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2287.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2113.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2314.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4084.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2723.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4629.10,,,percent of total billed charges,,,2450.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE U 155MM X_71071304 X_SMITH NEPHEW,10033602,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5446.00,1633.80,2287.32,4629.10,,2668.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2287.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2746.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2314.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4084.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2723.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4084.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4629.10,,,percent of total billed charges,,,2505.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT WIRE FIX THD HD X_100601 X_SMITH NEPHEW,10033604,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,403.00,120.90,156.36,342.55,,,,,,,,,,,,,,,,,,,,156.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,302.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.55,,,percent of total billed charges,,,181.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT WIRE FIX THD HD X_100601 X_SMITH NEPHEW,10033604,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,403.00,120.90,171.28,342.55,,,,,,,,,,,,,service not payable,,,,,,,203.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,201.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,302.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,342.55,,,percent of total billed charges,,,185.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EXTRACTOR ACUTWIST X_AI-EX20 X_ACUMED,10033605,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1050.00,315.00,407.40,892.5,,,,,,,,,,,,,,,,,,,,407.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,525.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.5,,,percent of total billed charges,,,472.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EXTRACTOR ACUTWIST X_AI-EX20 X_ACUMED,10033605,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1050.00,315.00,446.25,892.5,,,,,,,,,,,,,service not payable,,,,,,,529.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,787.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,525.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,787.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,892.5,,,percent of total billed charges,,,483.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEEDLE ACQUIRE FNB 19G,10033606,CDM,0272,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.13,2044.25,,1486.29,,,percent of total billed charges,,,,,,,,service not payable,1173.64,,,percent of total billed charges,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.13,,,percent of total billed charges,,,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1202.5,,,percent of total billed charges,,,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON CATH MINI TREK 1.2X15MM X_1012268-15U X_AB,10033607,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1203.00,360.90,511.27,1022.55,,743.45,,,percent of total billed charges,,,,,,,,service not payable,587.06,,,percent of total billed charges,,,606.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,511.27,,,percent of total billed charges,,,,,,,,,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,601.5,,,percent of total billed charges,,,,,,,,service not payable,902.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1022.55,,,percent of total billed charges,,,553.38,,,percent of total billed charges,,,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH TEMP SENSING 15 FR 5ML X_319416AM X_12747,10033651,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,146.00,43.80,62.05,124.10,,90.23,,,percent of total billed charges,,,,,,,,service not payable,71.25,,,percent of total billed charges,,,73.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.05,,,percent of total billed charges,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.0,,,percent of total billed charges,,,,,,,,service not payable,109.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,124.10,,,percent of total billed charges,,,67.16,,,percent of total billed charges,,,,,,,,,94.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDEWIRE STR 150/025 X_UWR1025 X_OLYMPUS AMERICA,10033764,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,140.29,,,percent of total billed charges,,,,,,,,service not payable,110.78,,,percent of total billed charges,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,147.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,147.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER CHCKFLO XL 10X38.5,10033766,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,450.00,135.00,191.25,382.5,,278.10,,,percent of total billed charges,,,,,,,,service not payable,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,191.25,,,percent of total billed charges,,,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,337.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH ANL2 CHKFLO 5F RNL DBL,10033767,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,318.00,95.40,135.15,270.30,,196.52,,,percent of total billed charges,,,,,,,,service not payable,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,135.15,,,percent of total billed charges,,,,,,,,,238.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,159.0,,,percent of total billed charges,,,,,,,,service not payable,238.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,206.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ILIAC 8.5X80 X_13018580 X_NUVASIVE,10033768,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ILIAC 8.5X80 X_13018580 X_NUVASIVE,10033768,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD-TI 110MM X_14355110 X_NUVASIVE,10033769,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD-TI 110MM X_14355110 X_NUVASIVE,10033769,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK 2.7X40MM,10033770,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK 2.7X40MM,10033770,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT AORTIC 20F 36X70MM,10033771,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,22791.00,6837.30,8842.91,19372.35,,11167.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9572.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8842.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9686.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17093.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11395.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19372.35,,,percent of total billed charges,,,10255.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT AORTIC 20F 36X70MM,10033771,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,22791.00,6837.30,9572.22,19372.35,,11167.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9572.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11495.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9686.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17093.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11395.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17093.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19372.35,,,percent of total billed charges,,,10483.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL SZ2 X_1294-33-120 X_DEPUY,10033772,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL SZ2 X_1294-33-120 X_DEPUY,10033772,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP 2X28MM AUTOFIX X_141-2028 X_ARTHREX INC,10033924,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2580.00,774.00,1001.04,2193.0,,,,,,,,,,,,,,,,,,,,1001.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1096.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1935.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1290.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2193.0,,,percent of total billed charges,,,1161.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP 2X28MM AUTOFIX X_141-2028 X_ARTHREX INC,10033924,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2580.00,774.00,1096.5,2193.0,,,,,,,,,,,,,service not payable,,,,,,,1301.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1096.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1935.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1290.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1935.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2193.0,,,percent of total billed charges,,,1186.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COUNTERSINK CANN 2X2.5MM X_907-1003 X_ARTHREX INC,10033925,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2432.00,729.60,943.62,2067.20,,,,,,,,,,,,,,,,,,,,943.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1824.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1216.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2067.20,,,percent of total billed charges,,,1094.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COUNTERSINK CANN 2X2.5MM X_907-1003 X_ARTHREX INC,10033925,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2432.00,729.60,1033.60,2067.20,,,,,,,,,,,,,service not payable,,,,,,,1226.7,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1033.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1824.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1216.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1824.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2067.20,,,percent of total billed charges,,,1118.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y 5H 1.5MM,10034013,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,811.00,243.30,314.67,689.35,,,,,,,,,,,,,,,,,,,,314.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,608.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,405.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.35,,,percent of total billed charges,,,364.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y 5H 1.5MM,10034013,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,811.00,243.30,344.68,689.35,,,,,,,,,,,,,service not payable,,,,,,,409.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,344.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,608.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,405.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,608.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,689.35,,,percent of total billed charges,,,373.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ST LP 16H CP 1.5X6 X_25-316-00-91 X_KLS MART,10034014,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,667.00,200.10,258.80,566.95,,,,,,,,,,,,,,,,,,,,258.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,500.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,333.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,566.95,,,percent of total billed charges,,,300.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ST LP 16H CP 1.5X6 X_25-316-00-91 X_KLS MART,10034014,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,667.00,200.10,283.47,566.95,,,,,,,,,,,,,service not payable,,,,,,,336.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,283.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,500.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,333.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,500.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,566.95,,,percent of total billed charges,,,306.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KWIRE 1.35MMX170MM X_AR-8610K-43 X_ARTHREX INC,10034017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KWIRE 1.35MMX170MM X_AR-8610K-43 X_ARTHREX INC,10034017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4.3X30MM X_AR-8643-30 X_ARTHREX IN,10034018,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4.3X30MM X_AR-8643-30 X_ARTHREX IN,10034018,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4.3X34MM X_AR-8643-34 X_ARTHREX IN,10034019,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4.3X34MM X_AR-8643-34 X_ARTHREX IN,10034019,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4.3X46MM X_AR-8643-46 X_ARTHREX IN,10034020,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4.3X46MM X_AR-8643-46 X_ARTHREX IN,10034020,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4.3X48MM X_AR-8643-48 X_ARTHREX IN,10034021,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4.3X48MM X_AR-8643-48 X_ARTHREX IN,10034021,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP COCHLEAR HEALING PLUG 30MM,10034022,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,107.00,32.10,41.52,90.95,,,,,,,,,,,,,,,,,,,,41.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,48.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP COCHLEAR HEALING PLUG 30MM,10034022,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,90.95,,,,,,,,,,,,,service not payable,,,,,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,45.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,80.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,53.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,80.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Soft Tissue Drainage,10034203,CDM,0761,RC,10030,CPT,,,,,,outpatient,facility,,,2916.00,874.80,118.0,2478.60,,1802.09,,,percent of total billed charges,,,,,,,,,1423.01,,,percent of total billed charges,,,1470.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1239.3,,,percent of total billed charges,,,,,,,,,2187.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1458.0,,,percent of total billed charges,,,,,,,,,2187.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2478.60,,,percent of total billed charges,,,1341.36,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Soft Tissue Drainage,10034203,CDM,0761,RC,10030,CPT,05071,APC,,,,outpatient,facility,,,2916.00,874.80,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Soft Tissue Drainage,10034203,CDM,0761,RC,10030,CPT,4,EAPG,,,,outpatient,facility,,,2916.00,874.80,1546.90,3698.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3698.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3143.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1546.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1701.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Soft Tissue Drainage,10034204,CDM,0761,RC,10030,CPT,,,,,,outpatient,facility,,,2916.00,874.80,118.0,2478.60,,1802.09,,,percent of total billed charges,,,,,,,,,1423.01,,,percent of total billed charges,,,1470.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1239.3,,,percent of total billed charges,,,,,,,,,2187.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1458.0,,,percent of total billed charges,,,,,,,,,2187.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2478.60,,,percent of total billed charges,,,1341.36,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Soft Tissue Drainage,10034204,CDM,0761,RC,10030,CPT,05071,APC,,,,outpatient,facility,,,2916.00,874.80,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Soft Tissue Drainage,10034204,CDM,0761,RC,10030,CPT,4,EAPG,,,,outpatient,facility,,,2916.00,874.80,1546.90,3698.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3698.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3143.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1560.7,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1546.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1701.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LEAD RELIANCE G ACTIVE 64CM,10034220,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,9180.00,2754.00,3561.84,7803.0,,4498.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3855.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3561.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4590.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.0,,,percent of total billed charges,,,4131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD RELIANCE G ACTIVE 64CM,10034220,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,9180.00,2754.00,3855.60,7803.0,,4498.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3855.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4630.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4590.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7803.0,,,percent of total billed charges,,,4222.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG T10 4.1X24MM X_626824 X_STRYKER ORTHOPAE,10034223,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1393.00,417.90,540.48,1184.05,,,,,,,,,,,,,,,,,,,,540.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1184.05,,,percent of total billed charges,,,626.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG T10 4.1X24MM X_626824 X_STRYKER ORTHOPAE,10034223,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,,,,,,,,,,,,service not payable,,,,,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB DYNOGEN CARDIOVERT X4,10034224,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,42944.00,12883.20,16662.27,36502.40,,21042.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18036.48,,,percent of total billed charges,,Paid in addition to inpatient services ,16662.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32208.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21472.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36502.40,,,percent of total billed charges,,,19324.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB DYNOGEN CARDIOVERT X4,10034224,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,42944.00,12883.20,18036.48,36502.40,,21042.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18036.48,,,percent of total billed charges,,Paid in addition to outpatient services ,21660.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18251.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32208.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21472.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32208.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36502.40,,,percent of total billed charges,,,19754.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCP KNEE X_414.502 X_ZIMMER BIOMET,10034330,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,12024.00,3607.20,4665.31,10220.4,,5891.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5050.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4665.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5110.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9018.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6012.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10220.4,,,percent of total billed charges,,,5410.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SCP KNEE X_414.502 X_ZIMMER BIOMET,10034330,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,12024.00,3607.20,5050.08,10220.4,,5891.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5050.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6064.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5110.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9018.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6012.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9018.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10220.4,,,percent of total billed charges,,,5531.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCP KNEE X_414.502 X_ZIMMER BIOMET,10034330,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,12024.00,3607.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATHETER DIL MINI TREK 1.2X6MM X_1012401-06Z X_ABB,10034331,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.4X12MM X_656012 X_STRYKER ORTHOPAE,10034333,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1208.00,362.40,468.70,1026.8,,,,,,,,,,,,,,,,,,,,468.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1026.8,,,percent of total billed charges,,,543.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.4X12MM X_656012 X_STRYKER ORTHOPAE,10034333,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1208.00,362.40,513.40,1026.8,,,,,,,,,,,,,service not payable,,,,,,,609.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,906.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1026.8,,,percent of total billed charges,,,555.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.4X10MM,10034336,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.4X10MM,10034336,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.4X14MM_Stryker Corporation_656014,10034337,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2409.00,722.70,934.69,2047.65,,,,,,,,,,,,,,,,,,,,934.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1023.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1806.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2047.65,,,percent of total billed charges,,,1084.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.4X14MM_Stryker Corporation_656014,10034337,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2409.00,722.70,1023.82,2047.65,,,,,,,,,,,,,service not payable,,,,,,,1215.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1023.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1806.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1806.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2047.65,,,percent of total billed charges,,,1108.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SMRTLK RADIAL COLUMN L,10034338,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3126.00,937.80,1212.89,2657.10,,,,,,,,,,,,,,,,,,,,1212.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1328.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2344.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1563.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2657.10,,,percent of total billed charges,,,1406.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SMRTLK RADIAL COLUMN L,10034338,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3126.00,937.80,1328.55,2657.10,,,,,,,,,,,,,service not payable,,,,,,,1576.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1328.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2344.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1563.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2344.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2657.10,,,percent of total billed charges,,,1437.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR XTRA SHT LT 3H,10034339,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3512.00,1053.60,1362.66,2985.20,,,,,,,,,,,,,,,,,,,,1362.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1492.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1756.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2985.20,,,percent of total billed charges,,,1580.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR XTRA SHT LT 3H,10034339,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3512.00,1053.60,1492.60,2985.20,,,,,,,,,,,,,service not payable,,,,,,,1771.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1492.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2634.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1756.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2634.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2985.20,,,percent of total billed charges,,,1615.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAR LK FT T8 NS 2.7X28MM,10034340,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,698.00,209.40,270.82,593.30,,,,,,,,,,,,,,,,,,,,270.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,523.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,349.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,593.30,,,percent of total billed charges,,,314.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAR LK FT T8 NS 2.7X28MM,10034340,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,698.00,209.40,296.65,593.30,,,,,,,,,,,,,service not payable,,,,,,,352.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,296.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,523.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,349.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,523.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,593.30,,,percent of total billed charges,,,321.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LK T8 2.0X18MM,10034341,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1208.00,362.40,468.70,1026.8,,,,,,,,,,,,,,,,,,,,468.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1026.8,,,percent of total billed charges,,,543.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LK T8 2.0X18MM,10034341,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1208.00,362.40,513.40,1026.8,,,,,,,,,,,,,service not payable,,,,,,,609.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,906.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1026.8,,,percent of total billed charges,,,555.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3X32MM X_71103232S X_SMITH NEPHEW,10034343,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1078.00,323.40,418.26,916.30,,,,,,,,,,,,,,,,,,,,418.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916.30,,,percent of total billed charges,,,485.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3X32MM X_71103232S X_SMITH NEPHEW,10034343,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1078.00,323.40,458.15,916.30,,,,,,,,,,,,,service not payable,,,,,,,543.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,808.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,916.30,,,percent of total billed charges,,,495.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3X26MM X_71103226S X_SMITH NEPHEW,10034344,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1078.00,323.40,418.26,916.30,,,,,,,,,,,,,,,,,,,,418.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916.30,,,percent of total billed charges,,,485.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3X26MM X_71103226S X_SMITH NEPHEW,10034344,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1078.00,323.40,458.15,916.30,,,,,,,,,,,,,service not payable,,,,,,,543.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,808.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,916.30,,,percent of total billed charges,,,495.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP NO12 40X170MM 132DEG X_6051-1240S X_STRYK,10034345,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP NO12 40X170MM 132DEG X_6051-1240S X_STRYK,10034345,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACU-LOC EX STAND PLATE X_70-0063 X_ACUMED,10034346,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2985.00,895.50,1158.18,2537.25,,,,,,,,,,,,,,,,,,,,1158.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1268.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2238.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1492.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2537.25,,,percent of total billed charges,,,1343.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACU-LOC EX STAND PLATE X_70-0063 X_ACUMED,10034346,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2985.00,895.50,1268.62,2537.25,,,,,,,,,,,,,service not payable,,,,,,,1505.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1268.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2238.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1492.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2238.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2537.25,,,percent of total billed charges,,,1373.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT BONE EXT FIX WIRE THD HD,10034348,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,403.00,120.90,156.36,342.55,,,,,,,,,,,,,,,,,,,,156.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,302.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.55,,,percent of total billed charges,,,181.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT BONE EXT FIX WIRE THD HD,10034348,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,403.00,120.90,171.28,342.55,,,,,,,,,,,,,service not payable,,,,,,,203.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,201.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,302.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,342.55,,,percent of total billed charges,,,185.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PERC AVISTA KIT 56CM,10034816,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PERC AVISTA KIT 56CM,10034816,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER GUIDE LAUNCH X_LA6HSI X_MEDTRONIC,10034817,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 6X36X120,10034818,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 6X36X120,10034818,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VISI-PRO 9X37MM X_PBX35-09-37-080 X_MEDTRONI,10034819,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VISI-PRO 9X37MM X_PBX35-09-37-080 X_MEDTRONI,10034819,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANTERIOR RT X_AR-8970AR X_ARTHREX INC,10034820,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6803.00,2040.90,2639.56,5782.55,,3333.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2857.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2639.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2891.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5102.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3401.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5782.55,,,percent of total billed charges,,,3061.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANTERIOR RT X_AR-8970AR X_ARTHREX INC,10034820,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6803.00,2040.90,2857.26,5782.55,,3333.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2857.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3431.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2891.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5102.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3401.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5102.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5782.55,,,percent of total billed charges,,,3129.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 4.5X18MM X_AR-8545L-18 X_ARTHREX INC,10034821,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 4.5X18MM X_AR-8545L-18 X_ARTHREX INC,10034821,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 4.5X36MM,10034822,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 4.5X36MM,10034822,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 4.5X40MM X_AR-8545-40 X_ARTHREX INC,10034823,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 4.5X40MM X_AR-8545-40 X_ARTHREX INC,10034823,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS LANDER WIDE FIELD X_OLTK-8.2 X_OCULAR INSTRUM,10034824,CDM,0276,RC,C1780,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS LANDER WIDE FIELD X_OLTK-8.2 X_OCULAR INSTRUM,10034824,CDM,0276,RC,C1780,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE PIN SCREW 1.2X5MM X_2307-90-004 X_DEPUY,10034827,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,809.00,242.70,313.89,687.65,,,,,,,,,,,,,,,,,,,,313.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,606.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,687.65,,,percent of total billed charges,,,364.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE PIN SCREW 1.2X5MM X_2307-90-004 X_DEPUY,10034827,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,809.00,242.70,343.82,687.65,,,,,,,,,,,,,service not payable,,,,,,,408.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,343.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,606.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,404.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,606.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,687.65,,,percent of total billed charges,,,372.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIB INSERT FXD BEARING SZ 10 10MM X_1506-00-010 X_,10034828,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIB INSERT FXD BEARING SZ 10 10MM X_1506-00-010 X_,10034828,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ10 RT,10034829,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ10 RT,10034829,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FX BEARING CRUC RET SZ10 10MM X_1516-21-010 X_DEPU,10034830,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FX BEARING CRUC RET SZ10 10MM X_1516-21-010 X_DEPU,10034830,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN KNEE THREADED HEADED 46MM,10034832,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,520.00,156.00,201.76,442.0,,,,,,,,,,,,,,,,,,,,201.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.0,,,percent of total billed charges,,,234.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN KNEE THREADED HEADED 46MM,10034832,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,,,,,,,,,,,,service not payable,,,,,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Hearing Screen Completed ABR - Newborn Hearing Scr,1003519,CDM,0471,RC,92620,CPT,,,,,,outpatient,facility,,,302.00,90.60,128.35,256.70,,186.64,,,percent of total billed charges,,,,,,,,,147.38,,,percent of total billed charges,,,152.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.35,,,percent of total billed charges,,,,,,,,,226.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,151.0,,,percent of total billed charges,,,,,,,,,226.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,256.70,,,percent of total billed charges,,,138.92,,,percent of total billed charges,,,,,,,,,200.0,,,per diem,,,,,,,,,,,,,,,176.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Hearing Screen Completed ABR - Newborn Hearing Scr,1003519,CDM,0471,RC,92620,CPT,05721,APC,,,,outpatient,facility,,,302.00,90.60,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Hearing Screen Completed ABR - Newborn Hearing Scr,1003519,CDM,0471,RC,92620,CPT,272,EAPG,,,,outpatient,facility,,,302.00,90.60,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Hearing Screen Completed OAE - Newborn Hearing Scr,1003520,CDM,0471,RC,92587,CPT,,,,,,outpatient,facility,,,304.00,91.20,129.20,258.40,,187.87,,,percent of total billed charges,,,,,,,,,148.35,,,percent of total billed charges,,,153.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.20,,,percent of total billed charges,,,,,,,,,228.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.0,,,percent of total billed charges,,,,,,,,,228.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,258.40,,,percent of total billed charges,,,139.84,,,percent of total billed charges,,,,,,,,,200.0,,,per diem,,,,,,,,,,,,,,,176.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Hearing Screen Completed OAE - Newborn Hearing Scr,1003520,CDM,0471,RC,92587,CPT,05722,APC,,,,outpatient,facility,,,304.00,91.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
Hearing Screen Completed OAE - Newborn Hearing Scr,1003520,CDM,0471,RC,92587,CPT,257,EAPG,,,,outpatient,facility,,,304.00,91.20,116.19,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,213.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW COMP CANN 4.0X40MM X_663040 X_STRYKER ORTHOP,10035323,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6079.00,1823.70,2358.65,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2358.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5167.15,,,percent of total billed charges,,,2735.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP CANN 4.0X40MM X_663040 X_STRYKER ORTHOP,10035323,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6079.00,1823.70,2553.18,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3066.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5167.15,,,percent of total billed charges,,,2796.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE WIRE UNTHRD 2X200MM X_705355 X_STRYKER ORTHO,10035326,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,695.00,208.50,295.38,590.75,,429.51,,,percent of total billed charges,,,,,,,,service not payable,339.16,,,percent of total billed charges,,,350.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,295.38,,,percent of total billed charges,,,,,,,,,521.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,347.5,,,percent of total billed charges,,,,,,,,service not payable,521.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,590.75,,,percent of total billed charges,,,319.70,,,percent of total billed charges,,,,,,,,,451.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,451.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER FOR 8-8MM SCREW X_663001 X_STRYKER ORTHOPAE,10035327,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,349.00,104.70,135.41,296.65,,,,,,,,,,,,,,,,,,,,135.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,157.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER FOR 8-8MM SCREW X_663001 X_STRYKER ORTHOPAE,10035327,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,349.00,104.70,148.32,296.65,,,,,,,,,,,,,service not payable,,,,,,,176.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,296.65,,,percent of total billed charges,,,160.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE TIB SZ 5 X_5536-B-500 X_STRYKER ORTHOPAE,10035328,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE TIB SZ 5 X_5536-B-500 X_STRYKER ORTHOPAE,10035328,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IMPACT 6MMX150MMX130CM,10035329,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,5607.00,1682.10,2382.97,4765.95,,3465.13,,,percent of total billed charges,,,,,,,,service not payable,2736.22,,,percent of total billed charges,,,2828.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2382.97,,,percent of total billed charges,,,,,,,,,4205.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,4205.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4765.95,,,percent of total billed charges,,,2579.22,,,percent of total billed charges,,,,,,,,,3644.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3644.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROMEND 12MMX2.5CM X_CNW12025 X_STRYKER,10035330,CDM,0278,RC,C9355,HCPCS,,,,,,inpatient,facility,,,4542.00,1362.60,1762.30,3860.70,,,,,,,,,,,,,,,,,,,,1762.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1930.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3406.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2271.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3860.70,,,percent of total billed charges,,,2043.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROMEND 12MMX2.5CM X_CNW12025 X_STRYKER,10035330,CDM,0278,RC,C9355,HCPCS,,,,,,outpatient,facility,,,4542.00,1362.60,1930.35,3860.70,,,,,,,,,,,,,service not payable,,,,,,,2290.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1930.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3406.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2271.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3406.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3860.70,,,percent of total billed charges,,,2089.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROMEND 12MMX2.5CM X_CNW12025 X_STRYKER,10035330,CDM,0278,RC,C9355,HCPCS,455,EAPG,,,,outpatient,facility,,,4542.00,1362.60,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROMEND 6MMX5.0CM X_CNW6050 X_STRYKER,10035331,CDM,0278,RC,C9355,HCPCS,,,,,,inpatient,facility,,,4932.00,1479.60,1913.62,4192.20,,,,,,,,,,,,,,,,,,,,1913.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2096.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3699.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2466.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4192.20,,,percent of total billed charges,,,2219.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROMEND 6MMX5.0CM X_CNW6050 X_STRYKER,10035331,CDM,0278,RC,C9355,HCPCS,,,,,,outpatient,facility,,,4932.00,1479.60,2096.10,4192.20,,,,,,,,,,,,,service not payable,,,,,,,2487.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2096.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3699.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2466.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3699.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4192.20,,,percent of total billed charges,,,2268.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROMEND 6MMX5.0CM X_CNW6050 X_STRYKER,10035331,CDM,0278,RC,C9355,HCPCS,455,EAPG,,,,outpatient,facility,,,4932.00,1479.60,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X32MM,10035332,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,737.00,221.10,285.96,626.45,,,,,,,,,,,,,,,,,,,,285.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,368.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,626.45,,,percent of total billed charges,,,331.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X32MM,10035332,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,737.00,221.10,313.22,626.45,,,,,,,,,,,,,service not payable,,,,,,,371.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,552.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,368.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,552.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,626.45,,,percent of total billed charges,,,339.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X75MM,10035333,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,154.00,46.20,59.75,130.90,,,,,,,,,,,,,,,,,,,,59.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,,69.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X75MM,10035333,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,154.00,46.20,65.45,130.90,,,,,,,,,,,,,service not payable,,,,,,,77.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,70.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4X44MM,10035337,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6079.00,1823.70,2358.65,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2358.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5167.15,,,percent of total billed charges,,,2735.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4X44MM,10035337,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6079.00,1823.70,2553.18,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3066.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5167.15,,,percent of total billed charges,,,2796.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER POSTERIOR LUMBAR 9MM 9.20X24.90X9.10MM X_26,10035338,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,8851.00,2655.30,3434.19,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3434.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.35,,,percent of total billed charges,,,3982.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER POSTERIOR LUMBAR 9MM 9.20X24.90X9.10MM X_26,10035338,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,8851.00,2655.30,3717.42,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4464.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6638.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7523.35,,,percent of total billed charges,,,4071.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR NAR CEM SZ4 LT,10035339,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR NAR CEM SZ4 LT,10035339,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INF-Application of on-body injector,10035345,CDM,0510,RC,96377,CPT,,,,,,outpatient,facility,,,165.00,49.50,75.90,140.25,,101.97,,,percent of total billed charges,,,,,,,,,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
INF-Application of on-body injector,10035345,CDM,0510,RC,96377,CPT,05691,APC,,,,outpatient,facility,,,165.00,49.50,42.44,101.63,,,,,,,,44.25,,,fee schedule,,,,,,,,,,,,,,,93.09,,,fee schedule,,,42.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",45.13,,,fee schedule,,,101.63,,,fee schedule,,,,,,,,,44.25,,,fee schedule,,,,,,,,,,,,,,,91.74,,,fee schedule,,,,,,,,,44.25,,,fee schedule,,,42.44,,,fee schedule,,,45.13,,,fee schedule,,,,,,,,,44.25,,,fee schedule,,,,,,,,,42.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",45.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.25,,,fee schedule,,,,,,,,,,,,,,,44.25,,,fee schedule,,,,,,,,,44.69,,,fee schedule,,,,,,,,
INF-Application of on-body injector,10035345,CDM,0510,RC,96377,CPT,109,EAPG,,,,outpatient,facility,,,165.00,49.50,32.24,398.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,338.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.24,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,35.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL ACET 54MM X_500-11-54E X_STRYKER ORTHOPAEDIC,10035489,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET 54MM X_500-11-54E X_STRYKER ORTHOPAEDIC,10035489,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ5 RT,10035494,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ5 RT,10035494,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN SONIL 2.1X4MM X_52-621-24-04 X_KLS MARTIN L P,10035495,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5908.00,1772.40,2292.30,5021.80,,2894.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2481.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2292.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2510.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4431.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2954.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5021.80,,,percent of total billed charges,,,2658.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN SONIL 2.1X4MM X_52-621-24-04 X_KLS MARTIN L P,10035495,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5908.00,1772.40,2481.36,5021.80,,2894.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2481.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2980.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2510.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4431.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2954.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4431.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5021.80,,,percent of total billed charges,,,2717.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RESORB 8HST X_52-075-08-04 X_KLS MARTIN L P,10035496,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1274.00,382.20,494.31,1082.90,,,,,,,,,,,,,,,,,,,,494.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,955.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,637.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1082.90,,,percent of total billed charges,,,573.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RESORB 8HST X_52-075-08-04 X_KLS MARTIN L P,10035496,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1274.00,382.20,541.45,1082.90,,,,,,,,,,,,,service not payable,,,,,,,642.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,541.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,955.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,637.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,955.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1082.90,,,percent of total billed charges,,,586.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DX IR1.5 6FR 2 HOLE 100CM,10035498,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM COMPIA MRI QUAD MMAM X_COMPIAMRIQDMMAM X_ME,10035499,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,64783.00,19434.90,25135.80,55065.55,,31743.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27208.86,,,percent of total billed charges,,Paid in addition to inpatient services ,25135.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27532.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,48587.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32391.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55065.55,,,percent of total billed charges,,,29152.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM COMPIA MRI QUAD MMAM X_COMPIAMRIQDMMAM X_ME,10035499,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,64783.00,19434.90,27208.86,55065.55,,31743.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27208.86,,,percent of total billed charges,,Paid in addition to outpatient services ,32676.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27532.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,48587.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32391.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,48587.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55065.55,,,percent of total billed charges,,,29800.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH POWERPICC SOLO TL 5F TRAY,10035500,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,840.00,252.00,357.0,714.0,,519.12,,,percent of total billed charges,,,,,,,,service not payable,409.92,,,percent of total billed charges,,,423.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,420.0,,,percent of total billed charges,,,,,,,,service not payable,630.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Apply Dermagraft,1003595,CDM,0761,RC,15275,CPT,,,,,,outpatient,facility,,,2985.00,895.50,118.0,2537.25,,1844.73,,,percent of total billed charges,,,,,,,,,1456.68,,,percent of total billed charges,,,1505.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1268.63,,,percent of total billed charges,,,,,,,,,2238.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1492.5,,,percent of total billed charges,,,,,,,,,2238.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2537.25,,,percent of total billed charges,,,1373.10,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Apply Dermagraft,1003595,CDM,0761,RC,15275,CPT,05054,APC,,,,outpatient,facility,,,2985.00,895.50,1682.57,4028.88,,,,,,,,1754.17,,,fee schedule,,,,,,,,,,,,,,,3690.17,,,fee schedule,,,1682.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1789.25,,,fee schedule,,,4028.88,,,fee schedule,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,,,,,,,3636.69,,,fee schedule,,,,,,,,,1754.17,,,fee schedule,,,1682.57,,,fee schedule,,,1789.25,,,fee schedule,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,1682.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1789.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,1771.64,,,fee schedule,,,,,,,,
WC-Apply Dermagraft,1003595,CDM,0761,RC,15275,CPT,56,EAPG,,,,outpatient,facility,,,2985.00,895.50,2726.14,4906.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4906.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4170.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2726.14,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2998.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Avulsion of Nail Plate - 1,1003596,CDM,0490,RC,11730,CPT,,,,,,outpatient,facility,,,300.00,90.00,138.0,2912.34,,300.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,151.32,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Avulsion of Nail Plate - 1,1003596,CDM,0490,RC,11730,CPT,05051,APC,,,,outpatient,facility,,,300.00,90.00,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Avulsion of Nail Plate - 1,1003596,CDM,0490,RC,11730,CPT,5,EAPG,,,,outpatient,facility,,,300.00,90.00,96.73,364.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,309.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,287.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,315.77,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Avulsion of Nail Plate >1,1003597,CDM,0490,RC,11732,CPT,,,,,,outpatient,facility,,,206.00,61.80,94.76,2912.34,,206.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,103.91,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,154.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,154.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,175.10,,,percent of total billed charges,,,94.76,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Avulsion of Nail Plate >1,1003597,CDM,0490,RC,11732,CPT,5,EAPG,,,,outpatient,facility,,,206.00,61.80,96.73,364.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,309.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,287.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,315.77,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Trim Nondystrophic Nails (Any Number),1003603,CDM,0761,RC,11719,CPT,,,,,,outpatient,facility,,,115.00,34.50,48.88,134.0,,71.07,,,percent of total billed charges,,,,,,,,,56.12,,,percent of total billed charges,,,58.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.88,,,percent of total billed charges,,,,,,,,,86.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.5,,,percent of total billed charges,,,,,,,,,86.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.75,,,percent of total billed charges,,,52.90,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Trim Nondystrophic Nails (Any Number),1003603,CDM,0761,RC,11719,CPT,05733,APC,,,,outpatient,facility,,,115.00,34.50,54.63,130.83,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,119.83,,,fee schedule,,,54.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",58.10,,,fee schedule,,,130.83,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,118.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,54.63,,,fee schedule,,,58.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,54.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",58.10,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,57.53,,,fee schedule,,,,,,,,
WC-Trim Nondystrophic Nails (Any Number),1003603,CDM,0761,RC,11719,CPT,5,EAPG,,,,outpatient,facility,,,115.00,34.50,96.73,364.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,309.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,96.73,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,287.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,315.77,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Debride bone <20 sq cm,1003606,CDM,0761,RC,11044,CPT,,,,,,outpatient,facility,,,2460.00,738.00,118.0,2091.0,,1520.28,,,percent of total billed charges,,,,,,,,,1200.48,,,percent of total billed charges,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Debride bone <20 sq cm,1003606,CDM,0761,RC,11044,CPT,05072,APC,,,,outpatient,facility,,,2460.00,738.00,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
WC-Debride bone <20 sq cm,1003606,CDM,0761,RC,11044,CPT,18,EAPG,,,,outpatient,facility,,,2460.00,738.00,1477.47,6298.20,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6298.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5353.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1477.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1477.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2903.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3193.81,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Debride subcut <20 sqcm,1003607,CDM,0761,RC,11042,CPT,,,,,,outpatient,facility,,,925.00,277.50,118.0,786.25,,571.65,,,percent of total billed charges,,,,,,,,,451.40,,,percent of total billed charges,,,466.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,393.13,,,percent of total billed charges,,,,,,,,,693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,462.5,,,percent of total billed charges,,,,,,,,,693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.25,,,percent of total billed charges,,,425.5,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Debride subcut <20 sqcm,1003607,CDM,0761,RC,11042,CPT,05052,APC,,,,outpatient,facility,,,925.00,277.50,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.0,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
WC-Debride subcut <20 sqcm,1003607,CDM,0761,RC,11042,CPT,17,EAPG,,,,outpatient,facility,,,925.00,277.50,555.36,1321.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1123.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,925.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1018.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Debride muscle and/or fascia <20 sq cm,1003608,CDM,0761,RC,11043,CPT,,,,,,outpatient,facility,,,984.00,295.20,118.0,836.40,,608.11,,,percent of total billed charges,,,,,,,,,480.19,,,percent of total billed charges,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Debride muscle and/or fascia <20 sq cm,1003608,CDM,0761,RC,11043,CPT,05053,APC,,,,outpatient,facility,,,984.00,295.20,563.05,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,563.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,563.05,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,563.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
WC-Debride muscle and/or fascia <20 sq cm,1003608,CDM,0761,RC,11043,CPT,17,EAPG,,,,outpatient,facility,,,984.00,295.20,555.36,1321.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1123.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,925.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1018.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Elec Stim Manual Ea 15 Min,1003611,CDM,0510,RC,97032,CPT,,,,,,outpatient,facility,,,135.00,40.50,13.30,114.75,,56.99,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.33,,,fee schedule,,,42.52,,,fee schedule,,,68.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.05,,,fee schedule,,,15.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.57,,,fee schedule,,,30.56,,,fee schedule,,,,,,,,,13.30,,,fee schedule,,,,,,,,,,,,,,service not payable,27.64,,,fee schedule,,,101.25,,,percent of total billed charges,,,13.33,,,fee schedule,,,15.99,,,fee schedule,,,13.6,,,fee schedule,,,,,,,,service not payable,13.30,,,fee schedule,,,,,,,,service not payable,15.99,,,fee schedule,,,13.6,,,fee schedule,,,,,,,,,114.75,,,percent of total billed charges,,,62.10,,,percent of total billed charges,,,,,,,,,87.75,,,percent of total billed charges,,,13.30,,,fee schedule,,,,,,,,,87.75,,,percent of total billed charges,,,13.33,,,fee schedule,,,,,,,,,13.33,,,fee schedule,,,,,,,,
WC-Elec Stim Manual Ea 15 Min,1003611,CDM,0510,RC,97032,CPT,493,EAPG,,,,outpatient,facility,,,135.00,40.50,72.54,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Excision of Nail - Partial or Complete,1003613,CDM,0761,RC,11750,CPT,,,,,,outpatient,facility,,,1149.00,344.70,118.0,976.65,,710.08,,,percent of total billed charges,,,,,,,,,560.71,,,percent of total billed charges,,,579.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.32,,,percent of total billed charges,,,,,,,,,861.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,861.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,976.65,,,percent of total billed charges,,,528.54,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Excision of Nail - Partial or Complete,1003613,CDM,0761,RC,11750,CPT,05052,APC,,,,outpatient,facility,,,1149.00,344.70,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.0,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
WC-Excision of Nail - Partial or Complete,1003613,CDM,0761,RC,11750,CPT,9,EAPG,,,,outpatient,facility,,,1149.00,344.70,602.64,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Graft Prep other than trunk first 100 sq cm (fa,1003614,CDM,0490,RC,15004,CPT,,,,,,outpatient,facility,,,1049.00,314.70,482.54,3666.78,,1049.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,529.12,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,786.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,786.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,891.65,,,percent of total billed charges,,,482.54,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Graft Prep other than trunk first 100 sq cm (fa,1003614,CDM,0490,RC,15004,CPT,05053,APC,,,,outpatient,facility,,,1049.00,314.70,563.05,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,563.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,563.05,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,563.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
WC-Graft Prep other than trunk first 100 sq cm (fa,1003614,CDM,0490,RC,15004,CPT,18,EAPG,,,,outpatient,facility,,,1049.00,314.70,1049.0,6298.20,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6298.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5353.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1049.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1049.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2903.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3193.81,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Graft Prep Trunk arms and legs each addl 100 sq,1003616,CDM,0490,RC,15003,CPT,,,,,,outpatient,facility,,,1049.00,314.70,482.54,2912.34,,1049.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,529.12,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,786.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,786.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,891.65,,,percent of total billed charges,,,482.54,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Graft Prep Trunk arms and legs each addl 100 sq,1003616,CDM,0490,RC,15003,CPT,17,EAPG,,,,outpatient,facility,,,1049.00,314.70,555.36,1321.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1123.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,925.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1018.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TRAY COMP RVS COBALT 44MM,10036178,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY COMP RVS COBALT 44MM,10036178,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING HUM SHLDR STD 44-36MM,10036179,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING HUM SHLDR STD 44-36MM,10036179,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-IandD Abscess - Multiple,1003618,CDM,0490,RC,10061,CPT,,,,,,outpatient,facility,,,510.00,153.00,234.60,2912.34,,510.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,257.24,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,433.5,,,percent of total billed charges,,,234.60,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-IandD Abscess - Multiple,1003618,CDM,0490,RC,10061,CPT,05052,APC,,,,outpatient,facility,,,510.00,153.00,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
WC-IandD Abscess - Multiple,1003618,CDM,0490,RC,10061,CPT,3,EAPG,,,,outpatient,facility,,,510.00,153.00,240.16,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW LK HEX 4.75X25MM STRL,10036180,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEX 4.75X25MM STRL,10036180,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 14X55MM,10036181,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 14X55MM,10036181,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SZ9 LNGH 118MM X_5569-C-2009 X_STRYKE,10036182,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8085.00,2425.50,3136.98,6872.25,,3961.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3395.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3136.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6063.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4042.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6872.25,,,percent of total billed charges,,,3638.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SZ9 LNGH 118MM X_5569-C-2009 X_STRYKE,10036182,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8085.00,2425.50,3395.70,6872.25,,3961.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3395.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4078.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3436.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6063.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4042.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6063.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6872.25,,,percent of total billed charges,,,3719.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL 44X19MM X_5552-S-4419 X_STRYKER ORTHO,10036183,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3667.00,1100.10,1422.80,3116.95,,,,,,,,,,,,,,,,,,,,1422.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3116.95,,,percent of total billed charges,,,1650.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL 44X19MM X_5552-S-4419 X_STRYKER ORTHO,10036183,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3667.00,1100.10,1558.47,3116.95,,,,,,,,,,,,,service not payable,,,,,,,1849.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3116.95,,,percent of total billed charges,,,1686.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT LEGION FEM RT SZ5,10036184,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT LEGION FEM RT SZ5,10036184,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL COMPONENT LEGION SZ3 RT X_71933652 X_SMITH,10036185,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL COMPONENT LEGION SZ3 RT X_71933652 X_SMITH,10036185,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-IandD Abscess - Single,1003619,CDM,0761,RC,10060,CPT,,,,,,outpatient,facility,,,510.00,153.00,118.0,433.5,,315.18,,,percent of total billed charges,,,,,,,,,248.88,,,percent of total billed charges,,,257.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.75,,,percent of total billed charges,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,433.5,,,percent of total billed charges,,,234.60,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-IandD Abscess - Single,1003619,CDM,0761,RC,10060,CPT,05051,APC,,,,outpatient,facility,,,510.00,153.00,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-IandD Abscess - Single,1003619,CDM,0761,RC,10060,CPT,3,EAPG,,,,outpatient,facility,,,510.00,153.00,240.16,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient minimal care < 10 min,1003624,CDM,0510,RC,99211,CPT,,,,,,outpatient,facility,,,450.00,135.00,11.49,382.5,,278.10,,,percent of total billed charges,,,,,,,,service not payable,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.49,,,fee schedule,,,,,,,,service not payable,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit estab patient minimal care < 10 min,1003624,CDM,0510,RC,99211,CPT,852,EAPG,,,,outpatient,facility,,,450.00,135.00,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient minimal care < 10 min,1003624,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,176.64,326.40,,237.31,,,percent of total billed charges,,,,,,,,,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit estab patient minimal care < 10 min,1003624,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,384.00,115.20,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit estab patient minimal care < 10 min,1003624,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,384.00,115.20,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient high level 40-54 min,1003625,CDM,0940,RC,G0463,HCPCS,,,,,,outpatient,facility,,,450.00,135.00,191.25,949.0,,278.10,,,percent of total billed charges,,,,,,,,,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.25,,,percent of total billed charges,,,,,,,,,337.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,337.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,949.0,,,per diem,,,,,,,,,,,,,,,835.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit estab patient high level 40-54 min,1003625,CDM,0940,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,450.00,135.00,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit estab patient high level 40-54 min,1003625,CDM,0940,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,450.00,135.00,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient high level 40-54 min,1003625,CDM,0510,RC,99215,CPT,,,,,,outpatient,facility,,,427.00,128.10,196.42,362.95,,263.89,,,percent of total billed charges,,,,,,,,service not payable,208.38,,,percent of total billed charges,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,320.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,277.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,277.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit estab patient high level 40-54 min,1003625,CDM,0510,RC,99215,CPT,852,EAPG,,,,outpatient,facility,,,427.00,128.10,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient moderate 30-39 min,1003626,CDM,0413,RC,G0463,HCPCS,,,,,,outpatient,facility,,,352.00,105.60,149.60,647.0,,217.54,,,percent of total billed charges,,,,,,,,,171.78,,,percent of total billed charges,,,177.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.60,,,percent of total billed charges,,,,,,,,,264.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.0,,,percent of total billed charges,,,,,,,,,264.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,299.20,,,percent of total billed charges,,,161.92,,,percent of total billed charges,,,,,,,,,647.0,,,per diem,,,,,,,,,,,,,,,596.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit estab patient moderate 30-39 min,1003626,CDM,0413,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,352.00,105.60,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit estab patient moderate 30-39 min,1003626,CDM,0413,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,352.00,105.60,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient moderate 30-39 min,1003626,CDM,0510,RC,99214,CPT,,,,,,outpatient,facility,,,384.00,115.20,176.64,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit estab patient moderate 30-39 min,1003626,CDM,0510,RC,99214,CPT,852,EAPG,,,,outpatient,facility,,,384.00,115.20,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient low level 20-29 min,1003627,CDM,0413,RC,G0463,HCPCS,,,,,,outpatient,facility,,,352.00,105.60,149.60,647.0,,217.54,,,percent of total billed charges,,,,,,,,,171.78,,,percent of total billed charges,,,177.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.60,,,percent of total billed charges,,,,,,,,,264.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.0,,,percent of total billed charges,,,,,,,,,264.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,299.20,,,percent of total billed charges,,,161.92,,,percent of total billed charges,,,,,,,,,647.0,,,per diem,,,,,,,,,,,,,,,596.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit estab patient low level 20-29 min,1003627,CDM,0413,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,352.00,105.60,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit estab patient low level 20-29 min,1003627,CDM,0413,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,352.00,105.60,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient low level 20-29 min,1003627,CDM,0510,RC,99213,CPT,,,,,,outpatient,facility,,,560.00,168.00,257.60,476.0,,346.08,,,percent of total billed charges,,,,,,,,service not payable,273.28,,,percent of total billed charges,,,282.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,420.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,476.0,,,percent of total billed charges,,,257.60,,,percent of total billed charges,,,,,,,,,364.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,364.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit estab patient low level 20-29 min,1003627,CDM,0510,RC,99213,CPT,852,EAPG,,,,outpatient,facility,,,560.00,168.00,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient straightforward 10-19 m,1003628,CDM,0510,RC,99212,CPT,,,,,,outpatient,facility,,,318.00,95.40,146.28,270.30,,196.52,,,percent of total billed charges,,,,,,,,service not payable,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,238.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,206.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit estab patient straightforward 10-19 m,1003628,CDM,0510,RC,99212,CPT,852,EAPG,,,,outpatient,facility,,,318.00,95.40,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit estab patient straightforward 10-19 m,1003628,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,427.00,128.10,196.42,362.95,,263.89,,,percent of total billed charges,,,,,,,,,208.38,,,percent of total billed charges,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,277.55,,,percent of total billed charges,,,,,,,,,,,,,,,277.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit estab patient straightforward 10-19 m,1003628,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,427.00,128.10,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit estab patient straightforward 10-19 m,1003628,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,427.00,128.10,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient high level 60-74 min,1003630,CDM,0510,RC,99205,CPT,,,,,,outpatient,facility,,,572.00,171.60,263.12,486.20,,353.5,,,percent of total billed charges,,,,,,,,service not payable,279.14,,,percent of total billed charges,,,288.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,429.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,486.20,,,percent of total billed charges,,,263.12,,,percent of total billed charges,,,,,,,,,371.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,371.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit new patient high level 60-74 min,1003630,CDM,0510,RC,99205,CPT,852,EAPG,,,,outpatient,facility,,,572.00,171.60,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient high level 60-74 min,1003630,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,560.00,168.00,257.60,476.0,,346.08,,,percent of total billed charges,,,,,,,,,273.28,,,percent of total billed charges,,,282.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,420.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,476.0,,,percent of total billed charges,,,257.60,,,percent of total billed charges,,,,,,,,,364.0,,,percent of total billed charges,,,,,,,,,,,,,,,364.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit new patient high level 60-74 min,1003630,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,560.00,168.00,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit new patient high level 60-74 min,1003630,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,560.00,168.00,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient moderate level 45-59 min,1003631,CDM,0510,RC,99204,CPT,,,,,,outpatient,facility,,,422.00,126.60,194.12,358.70,,260.80,,,percent of total billed charges,,,,,,,,service not payable,205.94,,,percent of total billed charges,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,274.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,274.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit new patient moderate level 45-59 min,1003631,CDM,0510,RC,99204,CPT,852,EAPG,,,,outpatient,facility,,,422.00,126.60,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient moderate level 45-59 min,1003631,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,318.00,95.40,146.28,270.30,,196.52,,,percent of total billed charges,,,,,,,,,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit new patient moderate level 45-59 min,1003631,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,318.00,95.40,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit new patient moderate level 45-59 min,1003631,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,318.00,95.40,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient low level 30-44 min,1003632,CDM,0510,RC,99203,CPT,,,,,,outpatient,facility,,,327.00,98.10,150.42,277.95,,202.09,,,percent of total billed charges,,,,,,,,service not payable,159.58,,,percent of total billed charges,,,164.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,245.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,277.95,,,percent of total billed charges,,,150.42,,,percent of total billed charges,,,,,,,,,212.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,212.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit new patient low level 30-44 min,1003632,CDM,0510,RC,99203,CPT,852,EAPG,,,,outpatient,facility,,,327.00,98.10,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient low level 30-44 min,1003632,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,450.00,135.00,207.0,382.5,,278.10,,,percent of total billed charges,,,,,,,,,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit new patient low level 30-44 min,1003632,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,450.00,135.00,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit new patient low level 30-44 min,1003632,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,450.00,135.00,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient straightforward 15-29 min,1003633,CDM,0510,RC,99202,CPT,,,,,,outpatient,facility,,,240.00,72.00,110.40,204.0,,148.32,,,percent of total billed charges,,,,,,,,service not payable,117.12,,,percent of total billed charges,,,121.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,180.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,204.0,,,percent of total billed charges,,,110.40,,,percent of total billed charges,,,,,,,,,156.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,156.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-OP visit new patient straightforward 15-29 min,1003633,CDM,0510,RC,99202,CPT,852,EAPG,,,,outpatient,facility,,,240.00,72.00,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-OP visit new patient straightforward 15-29 min,1003633,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,572.00,171.60,263.12,486.20,,353.5,,,percent of total billed charges,,,,,,,,,279.14,,,percent of total billed charges,,,288.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,429.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,486.20,,,percent of total billed charges,,,263.12,,,percent of total billed charges,,,,,,,,,371.80,,,percent of total billed charges,,,,,,,,,,,,,,,371.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-OP visit new patient straightforward 15-29 min,1003633,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,572.00,171.60,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC-OP visit new patient straightforward 15-29 min,1003633,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,572.00,171.60,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Paring Benign Lesion - One,1003634,CDM,0761,RC,11055,CPT,,,,,,outpatient,facility,,,326.00,97.80,118.0,277.10,,201.47,,,percent of total billed charges,,,,,,,,,159.09,,,percent of total billed charges,,,164.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,,,,,,,244.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.0,,,percent of total billed charges,,,,,,,,,244.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,277.10,,,percent of total billed charges,,,149.96,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Paring Benign Lesion - One,1003634,CDM,0761,RC,11055,CPT,05051,APC,,,,outpatient,facility,,,326.00,97.80,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Paring Benign Lesion - One,1003634,CDM,0761,RC,11055,CPT,3,EAPG,,,,outpatient,facility,,,326.00,97.80,240.16,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Paring Benign Lesion >4,1003635,CDM,0761,RC,11057,CPT,,,,,,outpatient,facility,,,300.00,90.00,118.0,255.0,,185.40,,,percent of total billed charges,,,,,,,,,146.40,,,percent of total billed charges,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Paring Benign Lesion >4,1003635,CDM,0761,RC,11057,CPT,05051,APC,,,,outpatient,facility,,,300.00,90.00,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Paring Benign Lesion >4,1003635,CDM,0761,RC,11057,CPT,3,EAPG,,,,outpatient,facility,,,300.00,90.00,240.16,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Paring Benign Lesion 2-4,1003636,CDM,0510,RC,11056,CPT,,,,,,outpatient,facility,,,300.00,90.00,138.0,255.0,,185.40,,,percent of total billed charges,,,,,,,,,146.40,,,percent of total billed charges,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,195.0,,,percent of total billed charges,,,,,,,,,,,,,,,195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Paring Benign Lesion 2-4,1003636,CDM,0510,RC,11056,CPT,05051,APC,,,,outpatient,facility,,,300.00,90.00,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Paring Benign Lesion 2-4,1003636,CDM,0510,RC,11056,CPT,3,EAPG,,,,outpatient,facility,,,300.00,90.00,244.28,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-TCOM - Multi Level,1003637,CDM,0920,RC,93923,CPT,,,,,,outpatient,facility,,,356.00,106.80,151.30,1813.0,,334.59,,Procedure Lookup:  Procedure Code Tables:   [[AETNA VASCULAR DIAG PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA VASCULAR DIAG PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,249.66,,,fee schedule,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,1813.0,,,per diem,,,,,,,,,,,,,,,1595.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-TCOM - Multi Level,1003637,CDM,0920,RC,93923,CPT,05721,APC,,,,outpatient,facility,,,356.00,106.80,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
WC-TCOM - Multi Level,1003637,CDM,0920,RC,93923,CPT,80,EAPG,,,,outpatient,facility,,,356.00,106.80,241.11,741.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,741.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,630.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,314.96,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,346.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-TCOM - Single Level,1003638,CDM,0921,RC,93922,CPT,,,,,,outpatient,facility,,,218.00,65.40,92.65,481.0,,218.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA VASCULAR DIAG PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA VASCULAR DIAG PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,165.27,,,fee schedule,,,109.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.65,,,percent of total billed charges,,,,,,,,,163.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.0,,,percent of total billed charges,,,,,,,,,163.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,185.30,,,percent of total billed charges,,,100.28,,,percent of total billed charges,,,,,,,,,481.0,,,per diem,,,,,,,,,,,,,,,423.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-TCOM - Single Level,1003638,CDM,0921,RC,93922,CPT,05734,APC,,,,outpatient,facility,,,218.00,65.40,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
WC-TCOM - Single Level,1003638,CDM,0921,RC,93922,CPT,288,EAPG,,,,outpatient,facility,,,218.00,65.40,158.99,371.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,316.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,158.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,213.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,235.29,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Debride Open Wound - 20 sqcm or <,1003639,CDM,0761,RC,97597,CPT,,,,,,outpatient,facility,,,716.00,214.80,118.0,608.60,,442.49,,,percent of total billed charges,,,,,,,,,349.41,,,percent of total billed charges,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Debride Open Wound - 20 sqcm or <,1003639,CDM,0761,RC,97597,CPT,05051,APC,,,,outpatient,facility,,,716.00,214.80,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Debride Open Wound - 20 sqcm or <,1003639,CDM,0761,RC,97597,CPT,16,EAPG,,,,outpatient,facility,,,716.00,214.80,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Debride Open Wound - ea addl 20 sqcm,1003640,CDM,0761,RC,97598,CPT,,,,,,outpatient,facility,,,341.00,102.30,118.0,289.85,,210.74,,,percent of total billed charges,,,,,,,,service not payable,166.41,,,percent of total billed charges,,,172.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,144.93,,,percent of total billed charges,,,,,,,,,255.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,170.5,,,percent of total billed charges,,,,,,,,service not payable,255.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,289.85,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Debride Open Wound - ea addl 20 sqcm,1003640,CDM,0761,RC,97598,CPT,18,EAPG,,,,outpatient,facility,,,341.00,102.30,341.0,6298.20,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6298.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5353.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2903.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3193.81,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Neg Press Wd Tx using DME equip surface area,1003642,CDM,0761,RC,97605,CPT,,,,,,outpatient,facility,,,375.00,112.50,118.0,318.75,,231.75,,,percent of total billed charges,,,,,,,,,183.0,,,percent of total billed charges,,,189.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.38,,,percent of total billed charges,,,,,,,,,281.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.5,,,percent of total billed charges,,,,,,,,,281.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,318.75,,,percent of total billed charges,,,172.5,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Neg Press Wd Tx using DME equip surface area,1003642,CDM,0761,RC,97605,CPT,05051,APC,,,,outpatient,facility,,,375.00,112.50,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Neg Press Wd Tx using DME equip surface area,1003642,CDM,0761,RC,97605,CPT,16,EAPG,,,,outpatient,facility,,,375.00,112.50,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Neg Press Wd Tx using DME equip surface area >,1003643,CDM,0761,RC,97606,CPT,,,,,,outpatient,facility,,,716.00,214.80,118.0,608.60,,442.49,,,percent of total billed charges,,,,,,,,,349.41,,,percent of total billed charges,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Neg Press Wd Tx using DME equip surface area >,1003643,CDM,0761,RC,97606,CPT,05052,APC,,,,outpatient,facility,,,716.00,214.80,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
WC-Neg Press Wd Tx using DME equip surface area >,1003643,CDM,0761,RC,97606,CPT,17,EAPG,,,,outpatient,facility,,,716.00,214.80,555.36,1321.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1123.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,925.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1018.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH DXT JL3.5 100CM,10036952,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,43.26,,,percent of total billed charges,,,,,,,,service not payable,34.16,,,percent of total billed charges,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DXT JR4 100CM X_DXT6JR4 X_MEDTRONIC USA I,10036953,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,43.26,,,percent of total billed charges,,,,,,,,service not payable,34.16,,,percent of total billed charges,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DXT JL4 100CM X_DXT6JL4 X_MEDTRONIC USA I,10036954,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,43.26,,,percent of total billed charges,,,,,,,,service not payable,34.16,,,percent of total billed charges,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SIG TLIF LG 8MM X_368.328 X_GLOBUS,10037025,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13113.00,3933.90,5087.84,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5087.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,,5900.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SIG TLIF LG 8MM X_368.328 X_GLOBUS,10037025,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5507.46,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEDICLE 8.5X40MM X_124.484 X_GLOBUS,10037026,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEDICLE 8.5X40MM X_124.484 X_GLOBUS,10037026,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PCI CUSTOM PIE BENT X_60-000-90-09 X_KLS MAR,10037029,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,18014.00,5404.20,6989.43,15311.9,,8826.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7565.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6989.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7655.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13510.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9007.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15311.9,,,percent of total billed charges,,,8106.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PCI CUSTOM PIE BENT X_60-000-90-09 X_KLS MAR,10037029,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,18014.00,5404.20,7565.88,15311.9,,8826.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7565.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9086.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7655.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13510.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9007.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13510.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15311.9,,,percent of total billed charges,,,8286.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE X X_25-326-55-91 X_KLS MARTIN L P,10037033,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,840.00,252.00,325.92,714.0,,,,,,,,,,,,,,,,,,,,325.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,420.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,714.0,,,percent of total billed charges,,,378.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE X X_25-326-55-91 X_KLS MARTIN L P,10037033,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,840.00,252.00,357.0,714.0,,,,,,,,,,,,,service not payable,,,,,,,423.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,630.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,420.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,630.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ6 RT X_1504-00-206 X_DEPUY,10037034,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ6 RT X_1504-00-206 X_DEPUY,10037034,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ6 10MM,10037035,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ6 10MM,10037035,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR NAR CEM SZ5 LT,10037036,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR NAR CEM SZ5 LT,10037036,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 8X58MM 135CM,10037037,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 8X58MM 135CM,10037037,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Inferior Vena Cavagram,10037109,CDM,0320,RC,75825,CPT,,,,,,outpatient,facility,,,7474.00,2242.20,169.83,6681.42,,227.61,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,169.83,,,fee schedule,,,3769.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3176.45,,,percent of total billed charges,,,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3737.0,,,percent of total billed charges,,,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6352.90,,,percent of total billed charges,,,3438.04,,,percent of total billed charges,,,,,,,,,6681.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Inferior Vena Cavagram,10037109,CDM,0320,RC,75825,CPT,05183,APC,,,,outpatient,facility,,,7474.00,2242.20,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Inferior Vena Cavagram,10037109,CDM,0320,RC,75825,CPT,279,EAPG,,,,outpatient,facility,,,7474.00,2242.20,2147.06,4287.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4287.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3644.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2462.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2462.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2462.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2147.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2361.77,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Inferior Vena Cavagram,10037110,CDM,0320,RC,75825,CPT,,,,,,outpatient,facility,,,7474.00,2242.20,169.83,6681.42,,227.61,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,169.83,,,fee schedule,,,3769.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3176.45,,,percent of total billed charges,,,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3737.0,,,percent of total billed charges,,,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6352.90,,,percent of total billed charges,,,3438.04,,,percent of total billed charges,,,,,,,,,6681.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Inferior Vena Cavagram,10037110,CDM,0320,RC,75825,CPT,05183,APC,,,,outpatient,facility,,,7474.00,2242.20,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Inferior Vena Cavagram,10037110,CDM,0320,RC,75825,CPT,279,EAPG,,,,outpatient,facility,,,7474.00,2242.20,2147.06,4287.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4287.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3644.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2462.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2462.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2462.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2147.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2361.77,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TRAY POWERPICC X 1LUM4F 341950,10037127,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1545.00,463.50,656.63,1313.25,,954.81,,,percent of total billed charges,,,,,,,,service not payable,753.96,,,percent of total billed charges,,,779.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,656.63,,,percent of total billed charges,,,,,,,,,1158.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,772.5,,,percent of total billed charges,,,,,,,,service not payable,1158.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1313.25,,,percent of total billed charges,,,710.70,,,percent of total billed charges,,,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY POWERPICC X 2LUM5F 341951,10037129,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1518.00,455.40,645.15,1290.3,,938.12,,,percent of total billed charges,,,,,,,,service not payable,740.78,,,percent of total billed charges,,,765.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,645.15,,,percent of total billed charges,,,,,,,,,1138.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,1138.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1290.3,,,percent of total billed charges,,,698.28,,,percent of total billed charges,,,,,,,,,986.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,986.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY POWERPICC X 1LUM4F 341950,10037134,CDM,0272,RC,A4550,HCPCS,,,,,,outpatient,facility,,,1545.00,463.50,656.63,1313.25,,954.81,,,percent of total billed charges,,,,,,,,service not payable,753.96,,,percent of total billed charges,,,779.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,656.63,,,percent of total billed charges,,,,,,,,,1158.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,772.5,,,percent of total billed charges,,,,,,,,service not payable,1158.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1313.25,,,percent of total billed charges,,,710.70,,,percent of total billed charges,,,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY POWERPICC X 2LUM5F 341951,10037135,CDM,0272,RC,A4550,HCPCS,,,,,,outpatient,facility,,,1518.00,455.40,645.15,1290.3,,938.12,,,percent of total billed charges,,,,,,,,service not payable,740.78,,,percent of total billed charges,,,765.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,645.15,,,percent of total billed charges,,,,,,,,,1138.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,1138.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1290.3,,,percent of total billed charges,,,698.28,,,percent of total billed charges,,,,,,,,,986.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,986.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ROBERTS 5FR 90CM,10037152,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM MOD DXTEND D14 LG,10037153,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,19327.00,5798.10,7498.88,16427.95,,9470.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8117.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7498.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8213.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14495.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9663.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16427.95,,,percent of total billed charges,,,8697.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM MOD DXTEND D14 LG,10037153,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,19327.00,5798.10,8117.34,16427.95,,9470.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8117.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9748.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8213.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14495.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9663.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14495.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16427.95,,,percent of total billed charges,,,8890.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK CAGE ANCHOR L 14X22X30MM X_48662144 X_STRYKER,10037180,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK CAGE ANCHOR L 14X22X30MM X_48662144 X_STRYKER,10037180,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANCHOR LT 5X25,10037181,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANCHOR LT 5X25,10037181,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LOCKING COVER,10037182,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LOCKING COVER,10037182,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB AP CVD SZ5 8MM,10037183,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB AP CVD SZ5 8MM,10037183,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ5 8MM,10037184,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ5 8MM,10037184,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ULNAR LK 3H LT,10037185,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4000.00,1200.00,1552.0,3400.0,,,,,,,,,,,,,,,,,,,,1552.0,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1700.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3000.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2000.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.0,,,percent of total billed charges,,,1800.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ULNAR LK 3H LT,10037185,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4000.00,1200.00,1700.0,3400.0,,,,,,,,,,,,,service not payable,,,,,,,2017.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1700.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3000.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2000.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3000.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3400.0,,,percent of total billed charges,,,1840.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE INOGEN DF4 ENDOTAK ATRIAL X_8FBD X_BOSTON S,10037186,CDM,0275,RC,C1777,HCPCS,,,,,,inpatient,facility,,,52451.00,15735.30,20350.99,44583.35,,25700.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22029.42,,,percent of total billed charges,,Paid in addition to inpatient services ,20350.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22291.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,39338.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26225.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44583.35,,,percent of total billed charges,,,23602.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE INOGEN DF4 ENDOTAK ATRIAL X_8FBD X_BOSTON S,10037186,CDM,0275,RC,C1777,HCPCS,,,,,,outpatient,facility,,,52451.00,15735.30,22029.42,44583.35,,25700.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22029.42,,,percent of total billed charges,,Paid in addition to outpatient services ,26456.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,22291.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,39338.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26225.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,39338.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,44583.35,,,percent of total billed charges,,,24127.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SPEED 18X15X15MM,10037233,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5356.00,1606.80,2078.13,4552.60,,2624.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2249.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2078.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4017.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2678.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4552.60,,,percent of total billed charges,,,2410.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SPEED 18X15X15MM,10037233,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5356.00,1606.80,2249.52,4552.60,,2624.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2249.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2701.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4017.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2678.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4017.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4552.60,,,percent of total billed charges,,,2463.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SPEED 18X18X15MM,10037234,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5356.00,1606.80,2078.13,4552.60,,2624.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2249.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2078.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4017.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2678.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4552.60,,,percent of total billed charges,,,2410.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SPEED 18X18X15MM,10037234,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5356.00,1606.80,2249.52,4552.60,,2624.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2249.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2701.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4017.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2678.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4017.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4552.60,,,percent of total billed charges,,,2463.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SPEED 18X18X18MM,10037235,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5356.00,1606.80,2078.13,4552.60,,2624.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2249.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2078.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4017.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2678.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4552.60,,,percent of total billed charges,,,2410.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SPEED 18X18X18MM,10037235,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5356.00,1606.80,2249.52,4552.60,,2624.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2249.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2701.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4017.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2678.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4017.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4552.60,,,percent of total billed charges,,,2463.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACETABULAR CUP TRIDENT 60MM X_65C-3260 X_STRYKER O,10037236,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETABULAR CUP TRIDENT 60MM X_65C-3260 X_STRYKER O,10037236,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA BALLOON U35 8X40X130 X_U3513084 X_BARD,10037237,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW INTERFERENCE 6X23MM X_AR-1360C X_ARTHREX INC,10037238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1284.00,385.20,498.19,1091.40,,,,,,,,,,,,,,,,,,,,498.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1091.40,,,percent of total billed charges,,,577.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW INTERFERENCE 6X23MM X_AR-1360C X_ARTHREX INC,10037238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1284.00,385.20,545.70,1091.40,,,,,,,,,,,,,service not payable,,,,,,,647.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,963.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1091.40,,,percent of total billed charges,,,590.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR SHT RT 10H 76MM,10037239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3283.00,984.90,1273.80,2790.55,,,,,,,,,,,,,,,,,,,,1273.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2790.55,,,percent of total billed charges,,,1477.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR SHT RT 10H 76MM,10037239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3283.00,984.90,1395.27,2790.55,,,,,,,,,,,,,service not payable,,,,,,,1655.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2790.55,,,percent of total billed charges,,,1510.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE MICRO SCUTRAK2 24MM X_AT2-C24 X_ACUMED,10037240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2448.00,734.40,949.82,2080.80,,,,,,,,,,,,,,,,,,,,949.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2080.80,,,percent of total billed charges,,,1101.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE MICRO SCUTRAK2 24MM X_AT2-C24 X_ACUMED,10037240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2448.00,734.40,1040.40,2080.80,,,,,,,,,,,,,service not payable,,,,,,,1234.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2080.80,,,percent of total billed charges,,,1126.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER HUM TRIAL 9MM,10037241,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2903.00,870.90,1126.36,2467.55,,,,,,,,,,,,,,,,,,,,1126.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1233.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2177.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2467.55,,,percent of total billed charges,,,1306.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER HUM TRIAL 9MM,10037241,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2903.00,870.90,1233.77,2467.55,,,,,,,,,,,,,service not payable,,,,,,,1464.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1233.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2177.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2177.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2467.55,,,percent of total billed charges,,,1335.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STYLUS SIGMA HP ADJ TIBIAL,10037242,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15643.00,4692.90,6069.48,13296.55,,7665.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6570.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6069.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6648.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11732.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7821.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13296.55,,,percent of total billed charges,,,7039.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STYLUS SIGMA HP ADJ TIBIAL,10037242,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15643.00,4692.90,6570.06,13296.55,,7665.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6570.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7890.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6648.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11732.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7821.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11732.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13296.55,,,percent of total billed charges,,,7195.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LCS TIB RESC BLK 2DEG V/V,10037243,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7618.00,2285.40,2955.78,6475.30,,3732.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3199.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2955.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3237.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5713.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3809.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6475.30,,,percent of total billed charges,,,3428.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LCS TIB RESC BLK 2DEG V/V,10037243,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7618.00,2285.40,3199.56,6475.30,,3732.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3199.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3842.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3237.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5713.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3809.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5713.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6475.30,,,percent of total billed charges,,,3504.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SIGMA HP DIS FEM,10037244,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5961.00,1788.30,2312.87,5066.85,,2920.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2503.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2312.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2533.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4470.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2980.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5066.85,,,percent of total billed charges,,,2682.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SIGMA HP DIS FEM,10037244,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5961.00,1788.30,2503.62,5066.85,,2920.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2503.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3006.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2533.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4470.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2980.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4470.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5066.85,,,percent of total billed charges,,,2742.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR OFFSET 5.5X15MM X_124.970 X_GLOBUS,10037570,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2022.00,606.60,784.54,1718.7,,,,,,,,,,,,,,,,,,,,784.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.7,,,percent of total billed charges,,,909.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR OFFSET 5.5X15MM X_124.970 X_GLOBUS,10037570,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2022.00,606.60,859.35,1718.7,,,,,,,,,,,,,service not payable,,,,,,,1019.9,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1718.7,,,percent of total billed charges,,,930.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR OFFSET 5.5X20MM X_124.971 X_GLOBUS,10037571,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2022.00,606.60,784.54,1718.7,,,,,,,,,,,,,,,,,,,,784.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.7,,,percent of total billed charges,,,909.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR OFFSET 5.5X20MM X_124.971 X_GLOBUS,10037571,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2022.00,606.60,859.35,1718.7,,,,,,,,,,,,,service not payable,,,,,,,1019.9,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1718.7,,,percent of total billed charges,,,930.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PED REVLV 8.5X90MM X_185.085 X_GLOBUS,10037572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5328.00,1598.40,2067.26,4528.80,,2610.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2237.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2067.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2264.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3996.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2664.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4528.80,,,percent of total billed charges,,,2397.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PED REVLV 8.5X90MM X_185.085 X_GLOBUS,10037572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5328.00,1598.40,2237.76,4528.80,,2610.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2237.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2687.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2264.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3996.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2664.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3996.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4528.80,,,percent of total billed charges,,,2450.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR BIO-COMP 3X14.5MM X_AR-1934BCF-2 X_ARTHREX,10037574,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR BIO-COMP 3X14.5MM X_AR-1934BCF-2 X_ARTHREX,10037574,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SPN TI LK CRV 2LVL 30MM,10037575,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SPN TI LK CRV 2LVL 30MM,10037575,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKING CRSDRV 2.3X13MM,10037576,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKING CRSDRV 2.3X13MM,10037576,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CUSTOM SI MANDIBLE,10037577,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,24259.00,7277.70,9412.49,20620.15,,11886.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10188.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9412.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10310.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18194.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12129.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20620.15,,,percent of total billed charges,,,10916.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CUSTOM SI MANDIBLE,10037577,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,24259.00,7277.70,10188.78,20620.15,,11886.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10188.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12236.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10310.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18194.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12129.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18194.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20620.15,,,percent of total billed charges,,,11159.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON EXPAND 7X19MM 7FR,10037578,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,8818.00,2645.40,3747.65,7495.30,,5449.52,,,percent of total billed charges,,,,,,,,service not payable,4303.18,,,percent of total billed charges,,,4447.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3747.65,,,percent of total billed charges,,,,,,,,,6613.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4409.0,,,percent of total billed charges,,,,,,,,service not payable,6613.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7495.30,,,percent of total billed charges,,,4056.28,,,percent of total billed charges,,,,,,,,,5731.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5731.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA3 7.5X50MM,10037579,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA3 7.5X50MM,10037579,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RAD POST TI 5.5X35MM,10037580,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RAD POST TI 5.5X35MM,10037580,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE TIT 11X28X6DEGX11MM X_48955116 X_STRYKER,10037581,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13933.00,4179.90,5406.00,11843.05,,6827.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5851.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5406.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10449.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6966.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11843.05,,,percent of total billed charges,,,6269.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE TIT 11X28X6DEGX11MM X_48955116 X_STRYKER,10037581,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13933.00,4179.90,5851.86,11843.05,,6827.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5851.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7027.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5921.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10449.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6966.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10449.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11843.05,,,percent of total billed charges,,,6409.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB 6.0 MULTIPC 25.5 X_MA60AC-25.5 X_ALCON LA,10037583,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,678.00,203.40,263.06,576.30,,,,,,,,,,,,,,,,,,,,263.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,508.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.30,,,percent of total billed charges,,,305.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB 6.0 MULTIPC 25.5 X_MA60AC-25.5 X_ALCON LA,10037583,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,678.00,203.40,288.15,576.30,,,,,,,,,,,,,service not payable,,,,,,,341.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,288.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,508.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,508.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,576.30,,,percent of total billed charges,,,311.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 12.0,10037584,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 12.0,10037584,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 13.5 X_MTA3UO-13.5 X_ALC,10037585,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 13.5 X_MTA3UO-13.5 X_ALC,10037585,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 16.5,10037586,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 16.5,10037586,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 17.0 X_MTA3UO-17 X_ALCON,10037587,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 17.0 X_MTA3UO-17 X_ALCON,10037587,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 20.0,10037588,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 20.0,10037588,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 23.0 X_MTA3UO-23.0 X_ALC,10037590,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 23.0 X_MTA3UO-23.0 X_ALC,10037590,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR NAR CEM SZ5 RT,10037592,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR NAR CEM SZ5 RT,10037592,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN 3.2MM STEINMAN,10037594,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,781.00,234.30,303.03,663.85,,,,,,,,,,,,,,,,,,,,303.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,585.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,390.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,663.85,,,percent of total billed charges,,,351.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN 3.2MM STEINMAN,10037594,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,781.00,234.30,331.93,663.85,,,,,,,,,,,,,service not payable,,,,,,,393.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,331.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,585.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,390.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,585.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,663.85,,,percent of total billed charges,,,359.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN STEINMAN .125X2.5IN,10037595,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN STEINMAN .125X2.5IN,10037595,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Seed Localization Device,10037686,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,754.00,226.20,292.55,640.90,,,,,,,,,,,,,,,,,,,,292.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.90,,,percent of total billed charges,,,339.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Seed Localization Device,10037686,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,754.00,226.20,320.45,640.90,,,,,,,,,,,,,service not payable,,,,,,,380.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,320.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,640.90,,,percent of total billed charges,,,346.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Seed Localization Device,10037687,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,754.00,226.20,292.55,640.90,,,,,,,,,,,,,,,,,,,,292.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.90,,,percent of total billed charges,,,339.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Seed Localization Device,10037687,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,754.00,226.20,320.45,640.90,,,,,,,,,,,,,service not payable,,,,,,,380.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,320.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,640.90,,,percent of total billed charges,,,346.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Closed Tx Nasal bone fracture w/stabilization,10037774,CDM,0450,RC,21320,CPT,,,,,,outpatient,facility,,,5736.00,1720.80,774.0,4875.60,,3544.85,,,percent of total billed charges,,,,,,,,,2799.17,,,percent of total billed charges,,,2893.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4302.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4302.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4875.60,,,percent of total billed charges,,,2638.56,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Closed Tx Nasal bone fracture w/stabilization,10037774,CDM,0450,RC,21320,CPT,05164,APC,,,,outpatient,facility,,,5736.00,1720.80,1491.53,7142.89,,,,,,,,3110.0,,,fee schedule,,,,,,,,,,,,,,,6542.38,,,fee schedule,,,1491.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3172.20,,,fee schedule,,,7142.89,,,fee schedule,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,,,,,,,6447.56,,,fee schedule,,,,,,,,,3110.0,,,fee schedule,,,1491.53,,,fee schedule,,,3172.20,,,fee schedule,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,1491.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3172.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,3140.98,,,fee schedule,,,,,,,,
Closed Tx Nasal bone fracture w/stabilization,10037774,CDM,0450,RC,21320,CPT,41,EAPG,,,,outpatient,facility,,,5736.00,1720.80,669.25,4928.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4928.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4189.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1856.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2042.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW ASNIS CANN 8X65MM X_611065S X_STRYKER ORTHOP,10037784,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ASNIS CANN 8X65MM X_611065S X_STRYKER ORTHOP,10037784,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ASNIS CANN 8X70MM X_611070S X_STRYKER ORTHOP,10037785,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1137.00,341.10,441.16,966.45,,,,,,,,,,,,,,,,,,,,441.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,852.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.45,,,percent of total billed charges,,,511.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ASNIS CANN 8X70MM X_611070S X_STRYKER ORTHOP,10037785,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1137.00,341.10,483.22,966.45,,,,,,,,,,,,,service not payable,,,,,,,573.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,483.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,852.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,568.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,852.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,966.45,,,percent of total billed charges,,,523.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PACK CFP 60CM,10037786,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2339.00,701.70,994.08,1988.15,,1445.5,,,percent of total billed charges,,,,,,,,service not payable,1141.43,,,percent of total billed charges,,,1179.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.08,,,percent of total billed charges,,,,,,,,,1754.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1169.5,,,percent of total billed charges,,,,,,,,service not payable,1754.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1988.15,,,percent of total billed charges,,,1075.94,,,percent of total billed charges,,,,,,,,,1520.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1520.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PACK CFP 100CM,10037787,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2339.00,701.70,994.08,1988.15,,1445.5,,,percent of total billed charges,,,,,,,,service not payable,1141.43,,,percent of total billed charges,,,1179.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.08,,,percent of total billed charges,,,,,,,,,1754.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1169.5,,,percent of total billed charges,,,,,,,,service not payable,1754.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1988.15,,,percent of total billed charges,,,1075.94,,,percent of total billed charges,,,,,,,,,1520.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1520.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 3.0X26MM X_IH3026 X_STRYKER ORTHOPAEDIC,10037788,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 3.0X26MM X_IH3026 X_STRYKER ORTHOPAEDIC,10037788,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Injection Procedure Treatment of  Extremity Pseudo,10037816,CDM,0450,RC,36002,CPT,,,,,,outpatient,facility,,,1444.00,433.20,664.24,1227.40,,892.39,,,percent of total billed charges,,,,,,,,,704.67,,,percent of total billed charges,,,728.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1083.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1083.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1227.40,,,percent of total billed charges,,,664.24,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Injection Procedure Treatment of  Extremity Pseudo,10037816,CDM,0450,RC,36002,CPT,05181,APC,,,,outpatient,facility,,,1444.00,433.20,284.35,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,284.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,284.35,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,284.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
Injection Procedure Treatment of  Extremity Pseudo,10037816,CDM,0450,RC,36002,CPT,277,EAPG,,,,outpatient,facility,,,1444.00,433.20,918.22,2720.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2720.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2312.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1444.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1444.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1444.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,918.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1010.04,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PACEMAKER VALITUDE X4 IS-1/IS4,10037877,CDM,0278,RC,C2621,HCPCS,,,,,,inpatient,facility,,,20981.00,6294.30,8140.63,17833.85,,10280.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8812.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8140.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8916.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15735.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10490.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17833.85,,,percent of total billed charges,,,9441.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER VALITUDE X4 IS-1/IS4,10037877,CDM,0278,RC,C2621,HCPCS,,,,,,outpatient,facility,,,20981.00,6294.30,8812.02,17833.85,,10280.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8812.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10582.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8916.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15735.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10490.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15735.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17833.85,,,percent of total billed charges,,,9651.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEMORAL SZ3 10MM X_5541-A-302 X_STRYKER OR,10037878,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEMORAL SZ3 10MM X_5541-A-302 X_STRYKER OR,10037878,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB KEEL POR MBT SZ5,10037879,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB KEEL POR MBT SZ5,10037879,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ4 8MM X_1516-20-408 X_DEPUY,10037880,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ4 8MM X_1516-20-408 X_DEPUY,10037880,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ4 10MM,10037881,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ4 10MM,10037881,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X26MM X_72823126 X_SMITH NEPHEW,10037882,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,627.00,188.10,243.28,532.95,,,,,,,,,,,,,,,,,,,,243.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.95,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X26MM X_72823126 X_SMITH NEPHEW,10037882,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,627.00,188.10,266.47,532.95,,,,,,,,,,,,,service not payable,,,,,,,316.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,532.95,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X28MM X_72823128 X_SMITH NEPHEW,10037883,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,627.00,188.10,243.28,532.95,,,,,,,,,,,,,,,,,,,,243.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.95,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X28MM X_72823128 X_SMITH NEPHEW,10037883,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,627.00,188.10,266.47,532.95,,,,,,,,,,,,,service not payable,,,,,,,316.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,532.95,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN PF 2X14 X_71173807 X_SMITH NEPHEW,10037884,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,672.00,201.60,260.74,571.20,,,,,,,,,,,,,,,,,,,,260.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.20,,,percent of total billed charges,,,302.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN PF 2X14 X_71173807 X_SMITH NEPHEW,10037884,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,672.00,201.60,285.60,571.20,,,,,,,,,,,,,service not payable,,,,,,,338.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,571.20,,,percent of total billed charges,,,309.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE EVANS 6MM X403106 X_MUSCULOSKETAL TRANSPLANT,10037886,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3440.00,1032.00,1334.72,2924.0,,,,,,,,,,,,,,,,,,,,1334.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1462.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2580.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1720.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2924.0,,,percent of total billed charges,,,1548.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE EVANS 6MM X403106 X_MUSCULOSKETAL TRANSPLANT,10037886,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3440.00,1032.00,1462.0,2924.0,,,,,,,,,,,,,service not payable,,,,,,,1735.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1462.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2580.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1720.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2580.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2924.0,,,percent of total billed charges,,,1582.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VLP SM 2.7MM X_72824022S X_SMITH NEPHEW,10037887,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3514.00,1054.20,1363.43,2986.90,,,,,,,,,,,,,,,,,,,,1363.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2635.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1757.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.90,,,percent of total billed charges,,,1581.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VLP SM 2.7MM X_72824022S X_SMITH NEPHEW,10037887,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3514.00,1054.20,1493.45,2986.90,,,,,,,,,,,,,service not payable,,,,,,,1772.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1493.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2635.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1757.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2635.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2986.90,,,percent of total billed charges,,,1616.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Unlisted Procedure Male Genital System,10037971,CDM,0450,RC,55899,CPT,,,,,,outpatient,facility,,,571.00,171.30,262.66,880.0,,352.88,,,percent of total billed charges,,,,,,,,,278.65,,,percent of total billed charges,,,288.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,428.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,428.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,485.35,,,percent of total billed charges,,,262.66,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Unlisted Procedure Male Genital System,10037971,CDM,0450,RC,55899,CPT,05371,APC,,,,outpatient,facility,,,571.00,171.30,111.86,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,111.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,111.86,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,111.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
Unlisted Procedure Male Genital System,10037971,CDM,0450,RC,55899,CPT,180,EAPG,,,,outpatient,facility,,,571.00,171.30,571.0,7352.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7352.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6249.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,571.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,571.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2131.56,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2344.72,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DISC CERVICAL PROST 15X17X5MM,10038171,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC CERVICAL PROST 15X17X5MM,10038171,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INFUS CRAGGMCNAMAR 50X135,10038172,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5X70MM X_AR-8665-2870 X_ARTHREX INC,10038173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2514.00,754.20,975.43,2136.90,,,,,,,,,,,,,,,,,,,,975.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.90,,,percent of total billed charges,,,1131.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5X70MM X_AR-8665-2870 X_ARTHREX INC,10038173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,,,,,,,,,,,,service not payable,,,,,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP DBL 3H 30MM X_AR-8007-30 X_ARTHREX INC,10038174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP DBL 3H 30MM X_AR-8007-30 X_ARTHREX INC,10038174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5X26MM X_AR-8835L-26 X_ARTHREX INC,10038175,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X26MM X_AR-8835L-26 X_ARTHREX INC,10038175,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP DBL 2H 30MM X_AR-8006-30 X_ARTHREX INC,10038176,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP DBL 2H 30MM X_AR-8006-30 X_ARTHREX INC,10038176,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE SYSTEM IBV 9MM,10038179,CDM,0278,RC,C1726,HCPCS,,,,,,inpatient,facility,,,11311.00,3393.30,4388.67,9614.35,,5542.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4750.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4388.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4807.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9614.35,,,percent of total billed charges,,,5089.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE SYSTEM IBV 9MM,10038179,CDM,0278,RC,C1726,HCPCS,,,,,,outpatient,facility,,,11311.00,3393.30,4750.62,9614.35,,5542.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4750.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5705.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4807.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9614.35,,,percent of total billed charges,,,5203.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WALKER INLINE CLSD HEEL MD X_15530006 X_DEROYAL,10038514,CDM,0274,RC,L4360,HCPCS,,,,,,inpatient,facility,,,201.00,60.30,77.99,170.85,,,,,,,,,,,,,,,,,,,,77.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,150.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.85,,,percent of total billed charges,,,90.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER INLINE CLSD HEEL MD X_15530006 X_DEROYAL,10038514,CDM,0274,RC,L4360,HCPCS,,,,,,outpatient,facility,,,201.00,60.30,85.42,454.26,,,,,,,,197.78,,,fee schedule,,,,,,,,,101.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,416.07,,,fee schedule,,,201.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",201.74,,,fee schedule,,,454.26,,,fee schedule,,,,,,,,,197.78,,,fee schedule,,,,,,,,,85.42,,,percent of total billed charges,,Paid in addition to outpatient services ,410.04,,,fee schedule,,,150.75,,,percent of total billed charges,,,197.78,,,fee schedule,,,201.0,,,fee schedule,,,201.74,,,fee schedule,,,100.5,,,percent of total billed charges,,Paid in addition to outpatient services ,197.78,,,fee schedule,,,150.75,,,percent of total billed charges,,,201.0,,,fee schedule,,,201.74,,,fee schedule,,,,,,,,,170.85,,,percent of total billed charges,,,92.46,,,percent of total billed charges,,,,,,,,,,,,,,,197.78,,,fee schedule,,,,,,,,,,,,,,,197.78,,,fee schedule,,,,,,,,,197.78,,,fee schedule,,,,,,,,
STEM OMNI EON SZ8 35X135MM 127DEG X_6097-0835 X_ST,10038516,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM OMNI EON SZ8 35X135MM 127DEG X_6097-0835 X_ST,10038516,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 5MMX25CM VASC XRAY 120CM,10038517,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,22030.00,6609.00,8547.64,18725.5,,10794.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9252.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8547.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9362.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11015.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18725.5,,,percent of total billed charges,,,9913.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 5MMX25CM VASC XRAY 120CM,10038517,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,22030.00,6609.00,9252.60,18725.5,,10794.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9252.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11111.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9362.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16522.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11015.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16522.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18725.5,,,percent of total billed charges,,,10133.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L 9H LT X_50-407-09-09 X_KLS MARTIN L P,10038518,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L 9H LT X_50-407-09-09 X_KLS MARTIN L P,10038518,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L 7H RT X_50-405-07-09 X_KLS MARTIN L P,10038519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L 7H RT X_50-405-07-09 X_KLS MARTIN L P,10038519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L-SHAPE LP LT 4H,10038520,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L-SHAPE LP LT 4H,10038520,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y REG 6MM X_50-390-05-91 X_KLS MARTIN L P,10038521,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y REG 6MM X_50-390-05-91 X_KLS MARTIN L P,10038521,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR FX ANG 5H 7DEG RT X_VPPR-5-7 X_TRI-MED,10038522,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR FX ANG 5H 7DEG RT X_VPPR-5-7 X_TRI-MED,10038522,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG DISTAL FIB 5H RT X_AR-9943BR-05 X_ARTHR,10038523,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG DISTAL FIB 5H RT X_AR-9943BR-05 X_ARTHR,10038523,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR FT BC SUTUR 5.5X14.7MM,10038524,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1940.00,582.00,752.72,1649.0,,,,,,,,,,,,,,,,,,,,752.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,824.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1455.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,970.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1649.0,,,percent of total billed charges,,,873.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR FT BC SUTUR 5.5X14.7MM,10038524,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1940.00,582.00,824.5,1649.0,,,,,,,,,,,,,service not payable,,,,,,,978.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,824.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1455.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,970.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1455.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1649.0,,,percent of total billed charges,,,892.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTRAVERSE PTA 3X20X130CM X_U813032 X_BARD,10038525,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1012.00,303.60,430.10,860.20,,625.42,,,percent of total billed charges,,,,,,,,service not payable,493.86,,,percent of total billed charges,,,510.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,430.10,,,percent of total billed charges,,,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,506.0,,,percent of total billed charges,,,,,,,,service not payable,759.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,860.20,,,percent of total billed charges,,,465.52,,,percent of total billed charges,,,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN KNEE THREADED HEADED 65MM,10038526,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,520.00,156.00,201.76,442.0,,,,,,,,,,,,,,,,,,,,201.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.0,,,percent of total billed charges,,,234.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN KNEE THREADED HEADED 65MM,10038526,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,,,,,,,,,,,,service not payable,,,,,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN PROV FIXATION 3.2X11 4MM,10038527,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1502.00,450.60,582.78,1276.7,,,,,,,,,,,,,,,,,,,,582.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276.7,,,percent of total billed charges,,,675.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN PROV FIXATION 3.2X11 4MM,10038527,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,,,,,,,,,,,,service not payable,,,,,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON B5 2C DISP,10038528,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,773.00,231.90,328.52,657.05,,477.71,,,percent of total billed charges,,,,,,,,service not payable,377.22,,,percent of total billed charges,,,389.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.52,,,percent of total billed charges,,,,,,,,,579.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,386.5,,,percent of total billed charges,,,,,,,,service not payable,579.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,657.05,,,percent of total billed charges,,,355.58,,,percent of total billed charges,,,,,,,,,502.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,502.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER PINNACLE NEUTRAL 32X52MM,10038529,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4166.00,1249.80,1616.41,3541.10,,,,,,,,,,,,,,,,,,,,1616.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1770.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3124.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2083.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3541.10,,,percent of total billed charges,,,1874.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER PINNACLE NEUTRAL 32X52MM,10038529,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4166.00,1249.80,1770.55,3541.10,,,,,,,,,,,,,service not payable,,,,,,,2101.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1770.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3124.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2083.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3124.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3541.10,,,percent of total billed charges,,,1916.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NT 2.3X28MM X_CO-N2328 X_ACUMED,10038530,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NT 2.3X28MM X_CO-N2328 X_ACUMED,10038530,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE X X_25-325-55-91 X_KLS MARTIN L P,10038531,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,840.00,252.00,325.92,714.0,,,,,,,,,,,,,,,,,,,,325.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,420.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,714.0,,,percent of total billed charges,,,378.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE X X_25-325-55-91 X_KLS MARTIN L P,10038531,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,840.00,252.00,357.0,714.0,,,,,,,,,,,,,service not payable,,,,,,,423.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,630.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,420.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,630.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE SPECTRE 0.014X300 X_7387 X_VASCULAR SOLU,10038532,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,539.51,,,percent of total billed charges,,,,,,,,service not payable,426.02,,,percent of total billed charges,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,567.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,567.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BANDAGE ELASTIC COMPRESSION STRL 6IN X_3861000 X_3,10038538,CDM,0623,RC,A6451,HCPCS,,,,,,outpatient,facility,,,48.00,14.40,20.40,40.80,,29.66,,,percent of total billed charges,,,,,,,,service not payable,23.42,,,percent of total billed charges,,,24.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,20.40,,,percent of total billed charges,,,,,,,,,36.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.0,,,percent of total billed charges,,,,,,,,service not payable,36.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,40.80,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,,,,,,,31.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,31.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CNC LP TI PT 3.0X26MM,10038800,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CNC LP TI PT 3.0X26MM,10038800,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L PRFYLE ST 4H 1.3MM X_57-13402 X_STRYKER OR,10038801,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1279.00,383.70,496.25,1087.15,,,,,,,,,,,,,,,,,,,,496.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,543.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,959.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1087.15,,,percent of total billed charges,,,575.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L PRFYLE ST 4H 1.3MM X_57-13402 X_STRYKER OR,10038801,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1279.00,383.70,543.57,1087.15,,,,,,,,,,,,,service not payable,,,,,,,645.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,543.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,959.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,959.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1087.15,,,percent of total billed charges,,,588.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX BONE BIO4 2.5CC X_3102-2102 X_STRYKER ORTHO,10038802,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5921.00,1776.30,2297.35,5032.85,,2901.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2486.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2297.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2516.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4440.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2960.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5032.85,,,percent of total billed charges,,,2664.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX BONE BIO4 2.5CC X_3102-2102 X_STRYKER ORTHO,10038802,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5921.00,1776.30,2486.82,5032.85,,2901.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2486.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2986.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2516.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4440.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2960.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4440.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5032.85,,,percent of total billed charges,,,2723.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ACU-LOC 2 VDR HEX LINK,10038808,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1027.00,308.10,398.48,872.95,,,,,,,,,,,,,,,,,,,,398.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,770.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,872.95,,,percent of total billed charges,,,462.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ACU-LOC 2 VDR HEX LINK,10038808,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1027.00,308.10,436.47,872.95,,,,,,,,,,,,,service not payable,,,,,,,518.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,436.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,770.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,513.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,770.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,872.95,,,percent of total billed charges,,,472.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LK HEXALOBE 3.0X12MM X_30-0303 X_ACUMED,10038809,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,427.00,128.10,165.68,362.95,,,,,,,,,,,,,,,,,,,,165.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,192.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LK HEXALOBE 3.0X12MM X_30-0303 X_ACUMED,10038809,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,427.00,128.10,181.47,362.95,,,,,,,,,,,,,service not payable,,,,,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,320.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK VAR ANG 5.0X85MM,10038815,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1032.00,309.60,400.42,877.20,,,,,,,,,,,,,,,,,,,,400.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.20,,,percent of total billed charges,,,464.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK VAR ANG 5.0X85MM,10038815,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1032.00,309.60,438.60,877.20,,,,,,,,,,,,,service not payable,,,,,,,520.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,438.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,877.20,,,percent of total billed charges,,,474.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK VAR ANG 5.0X32MM,10038816,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1032.00,309.60,400.42,877.20,,,,,,,,,,,,,,,,,,,,400.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.20,,,percent of total billed charges,,,464.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK VAR ANG 5.0X32MM,10038816,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1032.00,309.60,438.60,877.20,,,,,,,,,,,,,service not payable,,,,,,,520.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,438.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,877.20,,,percent of total billed charges,,,474.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RAD POST TI 5.5X45MM,10038817,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RAD POST TI 5.5X45MM,10038817,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUMBAR 10X28X6 DEG 11MM X_48955106 X_STR,10038818,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13933.00,4179.90,5406.00,11843.05,,6827.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5851.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5406.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10449.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6966.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11843.05,,,percent of total billed charges,,,6269.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUMBAR 10X28X6 DEG 11MM X_48955106 X_STR,10038818,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13933.00,4179.90,5851.86,11843.05,,6827.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5851.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7027.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5921.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10449.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6966.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10449.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11843.05,,,percent of total billed charges,,,6409.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ 8 7MM X_1516-20-807 X_DEPUY,10038819,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ 8 7MM X_1516-20-807 X_DEPUY,10038819,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ8 LT,10038820,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ8 LT,10038820,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ARTHROCELL 5CC,10038821,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTHROCELL 5CC,10038821,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TORIC 22.0 X_ZCT300 22.0D X_ABBOTT,10038823,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TORIC 22.0 X_ZCT300 22.0D X_ABBOTT,10038823,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 13X55MM,10038824,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 13X55MM,10038824,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWIVELK BC DL 4.75X22MM,10038825,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWIVELK BC DL 4.75X22MM,10038825,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INFUS CRAGGMCNAMAR 30X100,10038827,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK FEM PROX 15H 4.5MM RT X_74800515 X_SMITH,10038828,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4607.00,1382.10,1787.52,3915.95,,,,,,,,,,,,,,,,,,,,1787.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3455.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2303.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3915.95,,,percent of total billed charges,,,2073.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK FEM PROX 15H 4.5MM RT X_74800515 X_SMITH,10038828,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4607.00,1382.10,1957.97,3915.95,,,,,,,,,,,,,service not payable,,,,,,,2323.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1957.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3455.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2303.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3455.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3915.95,,,percent of total billed charges,,,2119.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L-SHAPE LP RT 4H X_50-375-04-91 X_KLS MARTIN,10038830,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L-SHAPE LP RT 4H X_50-375-04-91 X_KLS MARTIN,10038830,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE VALITUDE X4/ET X_8V4G X_BOSTON SCIENTIFIC C,10038831,CDM,0278,RC,C2621,HCPCS,,,,,,inpatient,facility,,,24226.00,7267.80,9399.69,20592.10,,11870.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10174.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9399.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10296.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20592.10,,,percent of total billed charges,,,10901.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE VALITUDE X4/ET X_8V4G X_BOSTON SCIENTIFIC C,10038831,CDM,0278,RC,C2621,HCPCS,,,,,,outpatient,facility,,,24226.00,7267.80,10174.92,20592.10,,11870.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10174.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12219.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10296.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,20592.10,,,percent of total billed charges,,,11143.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN STR 9MM X_FT750T X_AESCULAP,10038832,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN STR 9MM X_FT750T X_AESCULAP,10038832,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN STR 15MM X_FT780D X_AESCULAP,10038833,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN STR 15MM X_FT780D X_AESCULAP,10038833,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN STR 17MM X_FT792D X_AESCULAP,10038834,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN STR 17MM X_FT792D X_AESCULAP,10038834,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN STR 20MM X_FT790D X_AESCULAP,10038835,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN STR 20MM X_FT790D X_AESCULAP,10038835,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN CVD 6.5MM X_FT742T X_AESCULAP,10038836,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN CVD 6.5MM X_FT742T X_AESCULAP,10038836,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN CVD 15.3MM X_FT786T X_AESCULA,10038837,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN CVD 15.3MM X_FT786T X_AESCULA,10038837,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN CVD 5.4MM X_FT744T X_AESCULAP,10038838,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN CVD 5.4MM X_FT744T X_AESCULAP,10038838,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN CVD 6.4MM X_FT754T X_AESCULAP,10038839,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN CVD 6.4MM X_FT754T X_AESCULAP,10038839,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI FEN CVD 8MM X_FT764T X_AESCULAP,10038840,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI FEN CVD 8MM X_FT764T X_AESCULAP,10038840,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD CVD 7.4MM,10038841,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD CVD 7.4MM,10038841,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD CVD 8.4MM,10038842,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD CVD 8.4MM,10038842,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD CVD 10.5,10038843,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD CVD 10.5,10038843,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD CVD 13.7MM X_FT782T X_AESCULA,10038844,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD CVD 13.7MM X_FT782T X_AESCULA,10038844,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD CVD 10.3MM X_FT784T X_AESCULA,10038845,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD CVD 10.3MM X_FT784T X_AESCULA,10038845,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD BAYO 7MM X_FT748T X_AESCULAP,10038846,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD BAYO 7MM X_FT748T X_AESCULAP,10038846,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD BAYO 9MM X_FT758T X_AESCULAP,10038847,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD BAYO 9MM X_FT758T X_AESCULAP,10038847,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL TI STD BAYO 12MM X_FT759T X_AESCULAP,10038848,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL TI STD BAYO 12MM X_FT759T X_AESCULAP,10038848,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL FWD ANG 6.1MM X_FT603T X_AESCULAP,10038849,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL FWD ANG 6.1MM X_FT603T X_AESCULAP,10038849,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL FWD ANG 8MM X_FT613T X_AESCULAP,10038850,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL FWD ANG 8MM X_FT613T X_AESCULAP,10038850,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL FWD ANG 10.6MM X_FT623T X_AESCULAP,10038851,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL FWD ANG 10.6MM X_FT623T X_AESCULAP,10038851,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL FWD ANG 11.8MM X_FT763T X_AESCULAP,10038852,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL FWD ANG 11.8MM X_FT763T X_AESCULAP,10038852,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL FWD ANG 9MM X_FT810T X_AESCULAP,10038853,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL FWD ANG 9MM X_FT810T X_AESCULAP,10038853,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD RT ANG 5MM,10038854,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD RT ANG 5MM,10038854,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD RT ANG 7MM X_FT820T X_AESCULAP,10038855,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD RT ANG 7MM X_FT820T X_AESCULAP,10038855,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD RT ANG 10MM X_FT822T X_AESCULAP,10038856,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD RT ANG 10MM X_FT822T X_AESCULAP,10038856,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD UP ANG 6.7MM X_FT850T X_AESCULAP,10038857,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1804.00,541.20,699.95,1533.40,,,,,,,,,,,,,,,,,,,,699.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,902.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1533.40,,,percent of total billed charges,,,811.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD UP ANG 6.7MM X_FT850T X_AESCULAP,10038857,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1804.00,541.20,766.70,1533.40,,,,,,,,,,,,,service not payable,,,,,,,909.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,766.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,902.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1533.40,,,percent of total billed charges,,,829.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD UP ANG 9MM X_FT851T X_AESCULAP,10038858,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1804.00,541.20,699.95,1533.40,,,,,,,,,,,,,,,,,,,,699.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,902.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1533.40,,,percent of total billed charges,,,811.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD UP ANG 9MM X_FT851T X_AESCULAP,10038858,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1804.00,541.20,766.70,1533.40,,,,,,,,,,,,,service not payable,,,,,,,909.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,766.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,902.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1533.40,,,percent of total billed charges,,,829.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD OVR ANG 7MM X_FT830T X_AESCULAP,10038859,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD OVR ANG 7MM X_FT830T X_AESCULAP,10038859,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD SPOON 9.3MM X_FT832T X_AESCULAP,10038860,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD SPOON 9.3MM X_FT832T X_AESCULAP,10038860,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD SPOON 11.3MM X_FT833T X_AESCULAP,10038861,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD SPOON 11.3MM X_FT833T X_AESCULAP,10038861,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD LAT ANG 7MM X_FT746T X_AESCULAP,10038862,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD LAT ANG 7MM X_FT746T X_AESCULAP,10038862,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD LAT ANG 11.4MM X_FT761T X_AESCUL,10038863,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD LAT ANG 11.4MM X_FT761T X_AESCUL,10038863,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD LAT CVD 8.6MM X_FT747T X_AESCULA,10038864,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD LAT CVD 8.6MM X_FT747T X_AESCULA,10038864,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD ANG 7.8MM X_FT773T X_AESCULAP,10038865,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD ANG 7.8MM X_FT773T X_AESCULAP,10038865,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD RT BAYO 2.5MM X_FT770T X_AESCULA,10038866,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD RT BAYO 2.5MM X_FT770T X_AESCULA,10038866,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD RT BAYO 3.5,10038867,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD RT BAYO 3.5,10038867,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL STD RT BAYO 4.5MM X_FT772T X_AESCULA,10038868,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL STD RT BAYO 4.5MM X_FT772T X_AESCULA,10038868,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STR NARR 3MM X_FT680T X_AESCULA,10038869,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STR NARR 3MM X_FT680T X_AESCULA,10038869,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STR NARR 5MM X_FT690T X_AESCULA,10038870,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STR NARR 5MM X_FT690T X_AESCULA,10038870,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STR 3MM X_FT700T X_AESCULAP,10038871,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STR 3MM X_FT700T X_AESCULAP,10038871,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STR 5MM X_FT710T X_AESCULAP,10038872,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STR 5MM X_FT710T X_AESCULAP,10038872,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STR 7MM X_FT720T X_AESCULAP,10038873,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STR 7MM X_FT720T X_AESCULAP,10038873,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI SLT CVD NAR X_FT682T X_AESCULAP,10038874,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI SLT CVD NAR X_FT682T X_AESCULAP,10038874,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI SLT CVD 4.7MM X_FT692T X_AESCUL,10038875,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI SLT CVD 4.7MM X_FT692T X_AESCUL,10038875,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI SLT CVD 4MM X_FT711T X_AESCULAP,10038876,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI SLT CVD 4MM X_FT711T X_AESCULAP,10038876,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI SLT CVD 4.7MM X_FT712T X_AESCUL,10038877,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI SLT CVD 4.7MM X_FT712T X_AESCUL,10038877,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI LGHT CVD 4MM X_FT713T X_AESCULA,10038878,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI LGHT CVD 4MM X_FT713T X_AESCULA,10038878,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI CVD 5.6MM X_FT726T X_AESCULAP,10038879,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI CVD 5.6MM X_FT726T X_AESCULAP,10038879,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI CVD 6.4MM X_FT722T X_AESCULAP,10038880,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI CVD 6.4MM X_FT722T X_AESCULAP,10038880,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI CVD NAR 4,10038881,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI CVD NAR 4,10038881,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI CVD 4.1MM X_FT714T X_AESCULAP,10038882,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI CVD 4.1MM X_FT714T X_AESCULAP,10038882,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI CVD 5MM X_FT724T X_AESCULAP,10038883,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI CVD 5MM X_FT724T X_AESCULAP,10038883,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI LAT ANG 5MM X_FT716T X_AESCULAP,10038884,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI LAT ANG 5MM X_FT716T X_AESCULAP,10038884,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI TI LAT 4.7MM X_FT807T X_AESCULA,10038885,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI TI LAT 4.7MM X_FT807T X_AESCULA,10038885,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI BAYO 7MM X_FT728D X_AESCULAP,10038886,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI BAYO 7MM X_FT728D X_AESCULAP,10038886,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FWD ANG 7MM X_FT806T X_AESCULAP,10038887,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FWD ANG 7MM X_FT806T X_AESCULAP,10038887,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STR 7X4.6,10038888,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STR 7X4.6,10038888,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI CVD 5MM 70G,10038889,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI CVD 5MM 70G,10038889,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN 3/8.1MM X_FT597T X_AESCULAP,10038890,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN 3/8.1MM X_FT597T X_AESCULAP,10038890,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN 4/9.1MM X_FT598T X_AESCULAP,10038891,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN 4/9.1MM X_FT598T X_AESCULAP,10038891,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN 5/10.1MM X_FT599T X_AESCULA,10038892,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN 5/10.1MM X_FT599T X_AESCULA,10038892,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN STR 6MM X_FT600T X_AESCULAP,10038893,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN STR 6MM X_FT600T X_AESCULAP,10038893,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN STR 9MM X_FT610T X_AESCULAP,10038894,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN STR 9MM X_FT610T X_AESCULAP,10038894,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN STR 12MM X_FT620T X_AESCULA,10038895,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN STR 12MM X_FT620T X_AESCULA,10038895,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN FWD 7.5MM X_FT612T X_AESCUL,10038896,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN FWD 7.5MM X_FT612T X_AESCUL,10038896,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN FWD 10MM X_FT622T X_AESCULA,10038897,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN FWD 10MM X_FT622T X_AESCULA,10038897,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN FD 5MM X_FT604T X_AESCULAP,10038898,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1675.00,502.50,649.90,1423.75,,,,,,,,,,,,,,,,,,,,649.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1256.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,837.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.75,,,percent of total billed charges,,,753.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN FD 5MM X_FT604T X_AESCULAP,10038898,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1675.00,502.50,711.88,1423.75,,,,,,,,,,,,,service not payable,,,,,,,844.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,711.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1256.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,837.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1256.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1423.75,,,percent of total billed charges,,,770.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN RT 7.5MM X_FT614T X_AESCULA,10038899,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1675.00,502.50,649.90,1423.75,,,,,,,,,,,,,,,,,,,,649.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1256.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,837.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.75,,,percent of total billed charges,,,753.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN RT 7.5MM X_FT614T X_AESCULA,10038899,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1675.00,502.50,711.88,1423.75,,,,,,,,,,,,,service not payable,,,,,,,844.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,711.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1256.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,837.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1256.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1423.75,,,percent of total billed charges,,,770.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN 3/9.8MM X_FT637T X_AESCULAP,10038900,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN 3/9.8MM X_FT637T X_AESCULAP,10038900,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN 5/11.8MM X_FT639T X_AESCULA,10038901,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN 5/11.8MM X_FT639T X_AESCULA,10038901,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN STR 6MM X_FT640T X_AESCULAP,10038902,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN STR 6MM X_FT640T X_AESCULAP,10038902,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN STR 9MM X_FT650T X_AESCULAP,10038903,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN STR 9MM X_FT650T X_AESCULAP,10038903,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI STD 45D X_FT642T X_AESCULAP,10038904,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI STD 45D X_FT642T X_AESCULAP,10038904,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN FWD 7.5MM X_FT652T X_AESCUL,10038905,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN FWD 7.5MM X_FT652T X_AESCUL,10038905,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN FWD 10MM X_FT662T X_AESCULA,10038906,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN FWD 10MM X_FT662T X_AESCULA,10038906,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP YASARGIL MINI FEN RT 5MM X_FT644T X_AESCULAP,10038907,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1692.00,507.60,656.50,1438.2,,,,,,,,,,,,,,,,,,,,656.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,,761.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP YASARGIL MINI FEN RT 5MM X_FT644T X_AESCULAP,10038907,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1692.00,507.60,719.10,1438.2,,,,,,,,,,,,,service not payable,,,,,,,853.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,719.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1269.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,846.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1269.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,,778.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EVERA SR MRI X_EVERASMRIPEEM X_MEDTRONIC,10038908,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,51010.00,15303.00,19791.88,43358.5,,24994.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21424.20,,,percent of total billed charges,,Paid in addition to inpatient services ,19791.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21679.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38257.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25505.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43358.5,,,percent of total billed charges,,,22954.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EVERA SR MRI X_EVERASMRIPEEM X_MEDTRONIC,10038908,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,51010.00,15303.00,21424.20,43358.5,,24994.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21424.20,,,percent of total billed charges,,Paid in addition to outpatient services ,25729.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21679.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38257.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25505.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38257.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43358.5,,,percent of total billed charges,,,23464.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
REFLEX Striated Muscle Ab IgG Titer,10038909,CDM,0300,RC,86256,CPT,,,,,,outpatient,facility,,,47.00,14.10,11.45,39.95,,25.70,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.81,,,fee schedule,,,19.18,,,fee schedule,,,25.13,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.94,,,fee schedule,,,11.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.05,,,fee schedule,,,27.23,,,fee schedule,,,,,,,,,11.81,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,24.58,,,fee schedule,,,35.25,,,percent of total billed charges,,,11.81,,,fee schedule,,,11.45,,,fee schedule,,,12.05,,,fee schedule,,,18.33,,,fee schedule,,,11.81,,,fee schedule,,,35.25,,,percent of total billed charges,,,,,,,,,12.05,,,fee schedule,,,,,,,,,39.95,,,percent of total billed charges,,,21.62,,,percent of total billed charges,,,,,,,,,13.26,,,fee schedule,,,11.81,,,fee schedule,,,,,,,,,11.69,,,fee schedule,,,11.81,,,fee schedule,,,,,,,,,11.93,,,fee schedule,,,,,,,,
REFLEX Striated Muscle Ab IgG Titer,10038909,CDM,0300,RC,86256,CPT,394,EAPG,,,,outpatient,facility,,,47.00,14.10,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Herpes Simplex Virus 1/2 PCR. Other than blood,10039211,CDM,0300,RC,87529,CPT,,,,,,outpatient,facility,,,186.00,55.80,33.34,158.10,,149.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,139.5,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,139.5,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,158.10,,,percent of total billed charges,,,85.56,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Herpes Simplex Virus 1/2 PCR. Other than blood,10039211,CDM,0300,RC,87529,CPT,397,EAPG,,,,outpatient,facility,,,186.00,55.80,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM CEMENT ATTUNE 14X50MM,10039473,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CEMENT ATTUNE 14X50MM,10039473,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CRS SZ 5,10039474,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,19342.00,5802.60,7504.70,16440.70,,9477.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8123.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7504.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8220.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14506.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9671.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16440.70,,,percent of total billed charges,,,8703.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CRS SZ 5,10039474,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,19342.00,5802.60,8123.64,16440.70,,9477.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8123.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9756.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8220.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14506.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9671.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14506.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16440.70,,,percent of total billed charges,,,8897.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ7 RT,10039475,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ7 RT,10039475,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ7 8MM,10039476,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ7 8MM,10039476,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COLLAR GLBL UNI SZ6,10039477,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7228.00,2168.40,2804.46,6143.80,,3541.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3035.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2804.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3071.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5421.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3614.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6143.80,,,percent of total billed charges,,,3252.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAR GLBL UNI SZ6,10039477,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7228.00,2168.40,3035.76,6143.80,,3541.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3035.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3645.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3071.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5421.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3614.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5421.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6143.80,,,percent of total billed charges,,,3324.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD GLBL UNITE 40X15 ECC,10039478,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7054.00,2116.20,2736.95,5995.90,,3456.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2962.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2736.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2997.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5290.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3527.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5995.90,,,percent of total billed charges,,,3174.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLBL UNITE 40X15 ECC,10039478,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7054.00,2116.20,2962.68,5995.90,,3456.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2962.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3558.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2997.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5290.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3527.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5290.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5995.90,,,percent of total billed charges,,,3244.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRIP DAHL MILES TROCH W/2 CABLES X_6704-3-070 X_ST,10039481,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3757.00,1127.10,1457.72,3193.45,,,,,,,,,,,,,,,,,,,,1457.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2817.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1878.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3193.45,,,percent of total billed charges,,,1690.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRIP DAHL MILES TROCH W/2 CABLES X_6704-3-070 X_ST,10039481,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3757.00,1127.10,1596.72,3193.45,,,,,,,,,,,,,service not payable,,,,,,,1895.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1596.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2817.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1878.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2817.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3193.45,,,percent of total billed charges,,,1728.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG 10H 4.5X229MM X_71809312 X_SMITH NEPHEW,10039482,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2330.00,699.00,904.04,1980.5,,,,,,,,,,,,,,,,,,,,904.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,990.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1747.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.5,,,percent of total billed charges,,,1048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG 10H 4.5X229MM X_71809312 X_SMITH NEPHEW,10039482,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2330.00,699.00,990.25,1980.5,,,,,,,,,,,,,service not payable,,,,,,,1175.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,990.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1747.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1747.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1980.5,,,percent of total billed charges,,,1071.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 5F 4X80 130CM,10039484,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,2533.18,,,percent of total billed charges,,,,,,,,service not payable,2000.31,,,percent of total billed charges,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2049.5,,,percent of total billed charges,,,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH QUATTRO W/PREM ACCESS KIT,10039485,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,4363.00,1308.90,1854.28,3708.55,,2696.33,,,percent of total billed charges,,,,,,,,service not payable,2129.14,,,percent of total billed charges,,,2200.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1854.28,,,percent of total billed charges,,,,,,,,,3272.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2181.5,,,percent of total billed charges,,,,,,,,service not payable,3272.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3708.55,,,percent of total billed charges,,,2006.98,,,percent of total billed charges,,,,,,,,,2835.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2835.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT LEAD LINEAR TRIAL 70CM X_SC2218-70E X_BOSTON S,10039585,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,2514.00,754.20,975.43,2136.90,,,,,,,,,,,,,,,,,,,,975.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.90,,,percent of total billed charges,,,1131.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT LEAD LINEAR TRIAL 70CM X_SC2218-70E X_BOSTON S,10039585,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,,,,,,,,,,,,service not payable,,,,,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 15 X_MTA3U0-15.0 X_ALCON,10039588,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 15 X_MTA3U0-15.0 X_ALCON,10039588,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT LC SM 9X15X13 X_6809815 X_NUVASIVE,10039590,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6523.00,1956.90,2530.92,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2530.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5544.55,,,percent of total billed charges,,,2935.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT LC SM 9X15X13 X_6809815 X_NUVASIVE,10039590,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6523.00,1956.90,2739.66,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3290.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5544.55,,,percent of total billed charges,,,3000.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT LC SM 7X15X13 X_6807815 X_NUVASIVE,10039591,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6523.00,1956.90,2530.92,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2530.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5544.55,,,percent of total billed charges,,,2935.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT LC SM 7X15X13 X_6807815 X_NUVASIVE,10039591,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6523.00,1956.90,2739.66,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3290.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5544.55,,,percent of total billed charges,,,3000.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MSP Exam,10039657,CDM,0481,RC,33274,CPT,,,,,,outpatient,facility,,,46808.00,14042.40,5463.36,40166.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,23609.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32559.0,,,case rate,,,,,,,,,35106.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38305.0,,,case rate,,,,,,,,,35106.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39786.80,,,percent of total billed charges,,,21531.68,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,,,,,,,,35346.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MSP Exam,10039657,CDM,0481,RC,33274,CPT,05224,APC,,,,outpatient,facility,,,46808.00,14042.40,17542.16,42004.34,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,38473.0,,,fee schedule,,,17542.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18612.75,,,fee schedule,,,42004.34,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,37915.42,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,17542.16,,,fee schedule,,,18612.75,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,17542.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",18612.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,18429.93,,,fee schedule,,,,,,,,
MSP Exam,10039657,CDM,0481,RC,33274,CPT,86,EAPG,,,,outpatient,facility,,,46808.00,14042.40,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MSP Exam,10039658,CDM,0481,RC,33275,CPT,,,,,,outpatient,facility,,,8286.00,2485.80,3811.56,7120.36,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,4179.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7043.10,,,percent of total billed charges,,,3811.56,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MSP Exam,10039658,CDM,0481,RC,33275,CPT,05183,APC,,,,outpatient,facility,,,8286.00,2485.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
MSP Exam,10039658,CDM,0481,RC,33275,CPT,87,EAPG,,,,outpatient,facility,,,8286.00,2485.80,8286.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LEAD NEURO SPINAL TRIAL 70CM,10039685,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,2514.00,754.20,975.43,2136.90,,,,,,,,,,,,,,,,,,,,975.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.90,,,percent of total billed charges,,,1131.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD NEURO SPINAL TRIAL 70CM,10039685,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,,,,,,,,,,,,service not payable,,,,,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 6X60MM 120CM X_PHA060602A X_GORE MEDICA,10039690,CDM,0272,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,3029.44,,,percent of total billed charges,,,,,,,,service not payable,2392.18,,,percent of total billed charges,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,3186.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3186.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TROCAR TIP .094X12IN X_AR-8967KT-12 X_AR,10039692,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,143.00,42.90,60.77,121.55,,88.37,,,percent of total billed charges,,,,,,,,service not payable,69.78,,,percent of total billed charges,,,72.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,,,service not payable,107.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB M-D 13H RT 3.5X223MM X_71801113 X_SMITH,10039694,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3922.00,1176.60,1521.74,3333.70,,,,,,,,,,,,,,,,,,,,1521.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2941.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1961.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3333.70,,,percent of total billed charges,,,1764.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB M-D 13H RT 3.5X223MM X_71801113 X_SMITH,10039694,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3922.00,1176.60,1666.85,3333.70,,,,,,,,,,,,,service not payable,,,,,,,1978.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1666.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2941.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1961.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2941.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3333.70,,,percent of total billed charges,,,1804.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 3.5X6MM X_71821306 X_SMITH NEPHEW,10039695,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,108.00,32.40,41.90,91.80,,,,,,,,,,,,,,,,,,,,41.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,81.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.80,,,percent of total billed charges,,,48.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 3.5X6MM X_71821306 X_SMITH NEPHEW,10039695,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,108.00,32.40,45.90,91.80,,,,,,,,,,,,,service not payable,,,,,,,54.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,45.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,81.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,54.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,81.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,91.80,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RESORB SML 126X126X1MM X_52-310-130-04 X_KLS,10039696,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11168.00,3350.40,4333.18,9492.80,,5472.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4690.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4333.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4746.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8376.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5584.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9492.80,,,percent of total billed charges,,,5025.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RESORB SML 126X126X1MM X_52-310-130-04 X_KLS,10039696,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11168.00,3350.40,4690.56,9492.80,,5472.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4690.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5633.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4746.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8376.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5584.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8376.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9492.80,,,percent of total billed charges,,,5137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOC AKREOS AO 14.0 X_AO60P-14.0 X_BAUSCH AND,10039755,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 14.0 X_AO60P-14.0 X_BAUSCH AND,10039755,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.25X8MM,10039757,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.25X8MM,10039757,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.50X8MM,10039758,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.50X8MM,10039758,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X8MM,10039759,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X8MM,10039759,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.00X8MM,10039760,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.00X8MM,10039760,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.50X8MM,10039761,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.50X8MM,10039761,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.00X8MM,10039762,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.00X8MM,10039762,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.25X12MM,10039763,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.25X12MM,10039763,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.50X12MM,10039764,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.50X12MM,10039764,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X12MM,10039765,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X12MM,10039765,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.00X12MM,10039766,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.00X12MM,10039766,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.50X12MM,10039767,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.50X12MM,10039767,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.00X12MM,10039768,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.00X12MM,10039768,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 4.50X12MM,10039769,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 4.50X12MM,10039769,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.25X16MM,10039770,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.25X16MM,10039770,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X16MM,10039771,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X16MM,10039771,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.25X20MM,10039772,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.25X20MM,10039772,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X20MM,10039773,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X20MM,10039773,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.25X24MM,10039774,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.25X24MM,10039774,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X24MM,10039775,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X24MM,10039775,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.25X28MM,10039776,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.25X28MM,10039776,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X28MM,10039777,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X28MM,10039777,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 2.75X32MM,10039778,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 2.75X32MM,10039778,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT REBEL MR 3.00X32MM,10039779,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT REBEL MR 3.00X32MM,10039779,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DX SWVLK INST KIT 3.5X13.5MM,10039781,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1502.00,450.60,582.78,1276.7,,,,,,,,,,,,,,,,,,,,582.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276.7,,,percent of total billed charges,,,675.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DX SWVLK INST KIT 3.5X13.5MM,10039781,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,,,,,,,,,,,,service not payable,,,,,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETIC URIGLOW TRANSLUM,10040016,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,1284.00,385.20,498.19,1091.40,,,,,,,,,,,,,,,,,,,,498.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1091.40,,,percent of total billed charges,,,577.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETIC URIGLOW TRANSLUM,10040016,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,1284.00,385.20,545.70,1091.40,,,,,,,,,,,,,service not payable,,,,,,,647.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,963.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1091.40,,,percent of total billed charges,,,590.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA SYMM MTL BK S33X9MM X_5556-L-339 X_STRYKER,10040155,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA SYMM MTL BK S33X9MM X_5556-L-339 X_STRYKER,10040155,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR FIBERTAK DBL X_AR-3602-2 X_ARTHREX INC,10040156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2022.00,606.60,784.54,1718.7,,,,,,,,,,,,,,,,,,,,784.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.7,,,percent of total billed charges,,,909.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR FIBERTAK DBL X_AR-3602-2 X_ARTHREX INC,10040156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2022.00,606.60,859.35,1718.7,,,,,,,,,,,,,service not payable,,,,,,,1019.9,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1718.7,,,percent of total billed charges,,,930.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ7 16MM X_1516-40-716 X_DEPUY,10040157,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ7 16MM X_1516-40-716 X_DEPUY,10040157,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PARIETAL TEMPORAL X_PK619370 X_ZIMMER BIOM,10040158,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,31144.00,9343.20,12083.87,26472.40,,15260.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13080.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12083.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13236.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23358.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15572.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26472.40,,,percent of total billed charges,,,14014.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PARIETAL TEMPORAL X_PK619370 X_ZIMMER BIOM,10040158,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,31144.00,9343.20,13080.48,26472.40,,15260.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13080.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15709.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13236.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23358.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15572.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23358.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26472.40,,,percent of total billed charges,,,14326.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR ICD IS-1/DF-1-DR X_D153 X_BOSTON SCIENTI,10040159,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,32455.00,9736.50,12592.54,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13631.1,,,percent of total billed charges,,Paid in addition to inpatient services ,12592.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27586.75,,,percent of total billed charges,,,14604.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR ICD IS-1/DF-1-DR X_D153 X_BOSTON SCIENTI,10040159,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,32455.00,9736.50,13631.1,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13631.1,,,percent of total billed charges,,Paid in addition to outpatient services ,16370.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27586.75,,,percent of total billed charges,,,14929.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CMPRS FT STD 4.6X38MM,10040160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CMPRS FT STD 4.6X38MM,10040160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X9MM X_72412409 X_SMITH NEPHEW,10040164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X9MM X_72412409 X_SMITH NEPHEW,10040164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X10MM X_72412410 X_SMITH NEPHEW,10040165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X10MM X_72412410 X_SMITH NEPHEW,10040165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X12MM X_72412412 X_SMITH NEPHEW,10040166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X12MM X_72412412 X_SMITH NEPHEW,10040166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MICRO L-SHAPE LT X_25-310-85-91 X_KLS MARTIN,10040170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MICRO L-SHAPE LT X_25-310-85-91 X_KLS MARTIN,10040170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 18FRX28CM,10040386,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,675.47,,,percent of total billed charges,,,,,,,,service not payable,533.38,,,percent of total billed charges,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,710.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,710.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 22F X_VAMF3228C150TU X_MEDTRO,10040387,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 22F X_VAMF3228C150TU X_MEDTRO,10040387,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 22F X_VAMC3026C150TU X_MEDTRO,10040388,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,58172.00,17451.60,22570.74,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,22570.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49446.20,,,percent of total billed charges,,,26177.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 22F X_VAMC3026C150TU X_MEDTRO,10040388,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,58172.00,17451.60,24432.24,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,29341.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,49446.20,,,percent of total billed charges,,,26759.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 22F X_VAMC2828C150TU X_MEDTRO,10040389,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,58172.00,17451.60,22570.74,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,22570.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49446.20,,,percent of total billed charges,,,26177.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 22F X_VAMC2828C150TU X_MEDTRO,10040389,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,58172.00,17451.60,24432.24,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,29341.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,49446.20,,,percent of total billed charges,,,26759.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE SPINE PEEK SM 7X13X15 X_6907815 X_NUVASIVE,10040391,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,6523.00,1956.90,2530.92,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2530.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5544.55,,,percent of total billed charges,,,2935.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE SPINE PEEK SM 7X13X15 X_6907815 X_NUVASIVE,10040391,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,6523.00,1956.90,2739.66,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3290.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5544.55,,,percent of total billed charges,,,3000.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP 5H 2 PST 11MM 30D HFM3 X_4922-2-240 X_STRYKE,10040392,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2360.00,708.00,915.68,2006.0,,,,,,,,,,,,,,,,,,,,915.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1003.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1770.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2006.0,,,percent of total billed charges,,,1062.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP 5H 2 PST 11MM 30D HFM3 X_4922-2-240 X_STRYKE,10040392,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2360.00,708.00,1003.0,2006.0,,,,,,,,,,,,,service not payable,,,,,,,1190.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1003.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1770.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1770.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2006.0,,,percent of total billed charges,,,1085.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONN 11X400MM HFM3 X_4922-8-400 X_STRYKER ORTH,10040393,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1623.00,486.90,629.72,1379.55,,,,,,,,,,,,,,,,,,,,629.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1217.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,811.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1379.55,,,percent of total billed charges,,,730.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONN 11X400MM HFM3 X_4922-8-400 X_STRYKER ORTH,10040393,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1623.00,486.90,689.77,1379.55,,,,,,,,,,,,,service not payable,,,,,,,818.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,689.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1217.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,811.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1217.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1379.55,,,percent of total billed charges,,,746.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN SD ST 5MM 120X35MM X_5018-5-120 X_STRYKER ORTH,10040394,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,611.00,183.30,237.07,519.35,,,,,,,,,,,,,,,,,,,,237.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,458.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,305.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,519.35,,,percent of total billed charges,,,274.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN SD ST 5MM 120X35MM X_5018-5-120 X_STRYKER ORTH,10040394,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,611.00,183.30,259.68,519.35,,,,,,,,,,,,,service not payable,,,,,,,308.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,259.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,458.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,305.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,458.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,519.35,,,percent of total billed charges,,,281.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TRNSFX THRD 5/6X300MM X_5050-4-300 X_STRYKER O,10040395,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,569.00,170.70,220.77,483.65,,,,,,,,,,,,,,,,,,,,220.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,426.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,284.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.65,,,percent of total billed charges,,,256.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TRNSFX THRD 5/6X300MM X_5050-4-300 X_STRYKER O,10040395,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,569.00,170.70,241.82,483.65,,,,,,,,,,,,,service not payable,,,,,,,287.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,241.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,426.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,284.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,426.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,483.65,,,percent of total billed charges,,,261.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOGRAFT MAIN BODY X_BEA25-90/116-30 X_ENDOLOGIX,10040396,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,39008.00,11702.40,15135.10,33156.80,,19113.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16383.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15135.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16578.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29256.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19504.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33156.80,,,percent of total billed charges,,,17553.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOGRAFT MAIN BODY X_BEA25-90/116-30 X_ENDOLOGIX,10040396,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,39008.00,11702.40,16383.36,33156.80,,19113.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16383.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19675.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16578.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,29256.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19504.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29256.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,33156.80,,,percent of total billed charges,,,17943.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SIG CR PRCT SZ6 RT,10040397,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SIG CR PRCT SZ6 RT,10040397,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X8MM X_72412408 X_SMITH NEPHEW,10040398,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X8MM X_72412408 X_SMITH NEPHEW,10040398,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X6MM X_72412406 X_SMITH NEPHEW,10040399,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X6MM X_72412406 X_SMITH NEPHEW,10040399,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MECT Exam,10040493,CDM,0350,RC,62323,CPT,,,,,,outpatient,facility,,,2202.00,660.60,816.74,1871.7,,1360.84,,,percent of total billed charges,,,,,,,,,1074.58,,,percent of total billed charges,,,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.0,,,per diem,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MECT Exam,10040493,CDM,0350,RC,62323,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
MECT Exam,10040493,CDM,0350,RC,62323,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE 2.5MM 20 HOLE X_50-760-20-09 X_KLS MARTIN L,10040516,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3559.00,1067.70,1380.89,3025.15,,,,,,,,,,,,,,,,,,,,1380.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2669.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1779.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3025.15,,,percent of total billed charges,,,1601.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2.5MM 20 HOLE X_50-760-20-09 X_KLS MARTIN L,10040516,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3559.00,1067.70,1512.58,3025.15,,,,,,,,,,,,,service not payable,,,,,,,1795.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1512.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2669.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1779.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2669.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3025.15,,,percent of total billed charges,,,1637.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT OSTEOCHONDRAL CORE X_45647015 X_ALLOSOUR,10040518,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,14752.00,4425.60,5723.78,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5723.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12539.20,,,percent of total billed charges,,,6638.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT OSTEOCHONDRAL CORE X_45647015 X_ALLOSOUR,10040518,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,14752.00,4425.60,6195.84,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7440.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12539.20,,,percent of total billed charges,,,6785.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT OSTEOCHONDRAL CORE X_45647015 X_ALLOSOUR,10040518,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,14752.00,4425.60,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SUPRA 5.5X120MMX120CM 6F X_S-55-120-120-P6 X,10040562,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4173.07,8346.15,,6068.14,,,percent of total billed charges,,,,,,,,service not payable,4791.67,,,percent of total billed charges,,,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,6382.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6382.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 5.5X150MM,10040563,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 5.5X150MM,10040563,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VASC STINGRAY 300CM,10040564,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2684.00,805.20,1140.7,2281.40,,1658.71,,,percent of total billed charges,,,,,,,,service not payable,1309.79,,,percent of total billed charges,,,1353.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,,,,,,,2013.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1342.0,,,percent of total billed charges,,,,,,,,service not payable,2013.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2281.40,,,percent of total billed charges,,,1234.64,,,percent of total billed charges,,,,,,,,,1744.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1744.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON LP CATH 3.2X135CM 10MM X_393120SR X_BOSTON,10040565,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,7216.00,2164.80,3066.80,6133.60,,4459.49,,,percent of total billed charges,,,,,,,,service not payable,3521.41,,,percent of total billed charges,,,3639.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3066.80,,,percent of total billed charges,,,,,,,,,5412.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3608.0,,,percent of total billed charges,,,,,,,,service not payable,5412.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6133.60,,,percent of total billed charges,,,3319.36,,,percent of total billed charges,,,,,,,,,4690.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4690.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Sm intestinal endoscopy enteroscopy past 2nd,10041112,CDM,0750,RC,44378,CPT,,,,,,outpatient,facility,,,4228.00,1268.40,1944.88,4228.0,,4228.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,2132.60,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3593.80,,,percent of total billed charges,,,1944.88,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Sm intestinal endoscopy enteroscopy past 2nd,10041112,CDM,0750,RC,44378,CPT,05302,APC,,,,outpatient,facility,,,4228.00,1268.40,1744.90,4178.13,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,3826.87,,,fee schedule,,,1744.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1855.53,,,fee schedule,,,4178.13,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,3771.41,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,1744.90,,,fee schedule,,,1855.53,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,1744.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1855.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,1837.27,,,fee schedule,,,,,,,,
END-Sm intestinal endoscopy enteroscopy past 2nd,10041112,CDM,0750,RC,44378,CPT,135,EAPG,,,,outpatient,facility,,,4228.00,1268.40,2917.22,6867.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6867.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5837.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2917.22,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2917.22,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2917.22,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3555.70,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3911.27,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE OLECRANON 9H LFT X_70-0314 X_ACCUMED,10041147,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3508.00,1052.40,1361.10,2981.80,,,,,,,,,,,,,,,,,,,,1361.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1754.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.80,,,percent of total billed charges,,,1578.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OLECRANON 9H LFT X_70-0314 X_ACCUMED,10041147,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3508.00,1052.40,1490.90,2981.80,,,,,,,,,,,,,service not payable,,,,,,,1769.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1490.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2631.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1754.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2981.80,,,percent of total billed charges,,,1613.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CBL AND EXT OR 1.0X16X61CM,10041148,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CBL AND EXT OR 1.0X16X61CM,10041148,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD STIM TRIAL INFINION 50CM,10041149,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD STIM TRIAL INFINION 50CM,10041149,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE HT CNCT 250T .018X300 X_1012595 X_ABBOTT,10041150,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW UN3 AXS ST 1.5X5MM X_5615035 X_STRYKER CRANI,10041151,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,87.00,26.10,33.76,73.95,,,,,,,,,,,,,,,,,,,,33.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW UN3 AXS ST 1.5X5MM X_5615035 X_STRYKER CRANI,10041151,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,36.98,73.95,,,,,,,,,,,,,service not payable,,,,,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,43.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,65.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE UN3 STRT 16H 1.5MM,10041152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1543.00,462.90,598.68,1311.55,,,,,,,,,,,,,,,,,,,,598.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1157.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,771.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.55,,,percent of total billed charges,,,694.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE UN3 STRT 16H 1.5MM,10041152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1543.00,462.90,655.77,1311.55,,,,,,,,,,,,,service not payable,,,,,,,778.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,655.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1157.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,771.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1157.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1311.55,,,percent of total billed charges,,,709.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 LP 2H 1.5X1.7X16MM,10041153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,463.00,138.90,179.64,393.55,,,,,,,,,,,,,,,,,,,,179.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,347.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,231.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,393.55,,,percent of total billed charges,,,208.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 LP 2H 1.5X1.7X16MM,10041153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,463.00,138.90,196.78,393.55,,,,,,,,,,,,,service not payable,,,,,,,233.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,196.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,347.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,231.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,347.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,393.55,,,percent of total billed charges,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 BOX 2X2H SM,10041154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,969.00,290.70,375.97,823.65,,,,,,,,,,,,,,,,,,,,375.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,411.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,726.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.65,,,percent of total billed charges,,,436.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 BOX 2X2H SM,10041154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,969.00,290.70,411.82,823.65,,,,,,,,,,,,,service not payable,,,,,,,488.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,411.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,726.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,484.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,726.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,823.65,,,percent of total billed charges,,,445.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 BOX 2X2H LG W/TAB,10041155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1592.00,477.60,617.70,1353.2,,,,,,,,,,,,,,,,,,,,617.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1194.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,796.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1353.2,,,percent of total billed charges,,,716.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 BOX 2X2H LG W/TAB,10041155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1592.00,477.60,676.60,1353.2,,,,,,,,,,,,,service not payable,,,,,,,803.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,676.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1194.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,796.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1194.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1353.2,,,percent of total billed charges,,,732.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 BOX 2X2H LG,10041156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1500.00,450.00,582.0,1275.0,,,,,,,,,,,,,,,,,,,,582.0,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1125.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,750.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1275.0,,,percent of total billed charges,,,675.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 BOX 2X2H LG,10041156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1500.00,450.00,637.5,1275.0,,,,,,,,,,,,,service not payable,,,,,,,756.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,637.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1125.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,750.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1125.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1275.0,,,percent of total billed charges,,,690.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 BAR 4H,10041157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,675.00,202.50,261.90,573.75,,,,,,,,,,,,,,,,,,,,261.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,506.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,337.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,573.75,,,percent of total billed charges,,,303.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 BAR 4H,10041157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,675.00,202.50,286.88,573.75,,,,,,,,,,,,,service not payable,,,,,,,340.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,286.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,506.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,337.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,506.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,573.75,,,percent of total billed charges,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 RECT 2X2H,10041158,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1475.00,442.50,572.30,1253.75,,,,,,,,,,,,,,,,,,,,572.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,626.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1106.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,,663.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 RECT 2X2H,10041158,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1475.00,442.50,626.88,1253.75,,,,,,,,,,,,,service not payable,,,,,,,743.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,626.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1106.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1106.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,,678.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COVER BURRHOLE UN3 24MM TAB,10041159,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVER BURRHOLE UN3 24MM TAB,10041159,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE GAP UN3 6H SM,10041160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1663.00,498.90,645.24,1413.55,,,,,,,,,,,,,,,,,,,,645.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.55,,,percent of total billed charges,,,748.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE GAP UN3 6H SM,10041160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1663.00,498.90,706.77,1413.55,,,,,,,,,,,,,service not payable,,,,,,,838.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,706.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1413.55,,,percent of total billed charges,,,764.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SHUNT TAB UN3 14MM,10041161,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1343.00,402.90,521.08,1141.55,,,,,,,,,,,,,,,,,,,,521.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1007.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.55,,,percent of total billed charges,,,604.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SHUNT TAB UN3 14MM,10041161,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1343.00,402.90,570.77,1141.55,,,,,,,,,,,,,service not payable,,,,,,,677.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1007.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1007.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1141.55,,,percent of total billed charges,,,617.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SHUNT TAB UN3 20MM,10041162,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SHUNT TAB UN3 20MM,10041162,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE GAP UN3 6H LG,10041163,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1765.00,529.50,684.82,1500.25,,,,,,,,,,,,,,,,,,,,684.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,750.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1323.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,882.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1500.25,,,percent of total billed charges,,,794.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE GAP UN3 6H LG,10041163,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1765.00,529.50,750.12,1500.25,,,,,,,,,,,,,service not payable,,,,,,,890.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,750.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1323.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,882.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1323.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1500.25,,,percent of total billed charges,,,811.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE X UN3 4H,10041164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1395.00,418.50,541.26,1185.75,,,,,,,,,,,,,,,,,,,,541.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1046.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,697.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1185.75,,,percent of total billed charges,,,627.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE X UN3 4H,10041164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1395.00,418.50,592.88,1185.75,,,,,,,,,,,,,service not payable,,,,,,,703.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1046.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,697.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1046.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1185.75,,,percent of total billed charges,,,641.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 DOG BONE 2H RGD 12MM,10041165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,555.00,166.50,215.34,471.75,,,,,,,,,,,,,,,,,,,,215.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,249.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 DOG BONE 2H RGD 12MM,10041165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,555.00,166.50,235.88,471.75,,,,,,,,,,,,,service not payable,,,,,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,235.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,416.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,416.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE UN3 STRT 8H,10041166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,823.00,246.90,319.32,699.55,,,,,,,,,,,,,,,,,,,,319.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,617.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,411.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.55,,,percent of total billed charges,,,370.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE UN3 STRT 8H,10041166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,823.00,246.90,349.77,699.55,,,,,,,,,,,,,service not payable,,,,,,,415.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,349.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,617.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,411.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,617.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,699.55,,,percent of total billed charges,,,378.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG COMP BROAD 10H X_627570 X_STRYKER ORTHO,10041169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7649.00,2294.70,2967.81,6501.65,,3748.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3212.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2967.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3250.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5736.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3824.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6501.65,,,percent of total billed charges,,,3442.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG COMP BROAD 10H X_627570 X_STRYKER ORTHO,10041169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7649.00,2294.70,3212.58,6501.65,,3748.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3212.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3858.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3250.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5736.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3824.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5736.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6501.65,,,percent of total billed charges,,,3518.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG PERIPRSTH 5X16MM X_661316 X_STRYKER ORT,10041170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1425.00,427.50,552.90,1211.25,,,,,,,,,,,,,,,,,,,,552.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1068.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1211.25,,,percent of total billed charges,,,641.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG PERIPRSTH 5X16MM X_661316 X_STRYKER ORT,10041170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1425.00,427.50,605.62,1211.25,,,,,,,,,,,,,service not payable,,,,,,,718.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,605.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1068.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1068.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1211.25,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X24MM,10041171,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,154.00,46.20,59.75,130.90,,,,,,,,,,,,,,,,,,,,59.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,,69.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X24MM,10041171,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,154.00,46.20,65.45,130.90,,,,,,,,,,,,,service not payable,,,,,,,77.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,70.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X26MM,10041172,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,154.00,46.20,59.75,130.90,,,,,,,,,,,,,,,,,,,,59.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,,69.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X26MM,10041172,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,154.00,46.20,65.45,130.90,,,,,,,,,,,,,service not payable,,,,,,,77.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,70.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X30MM,10041173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X30MM,10041173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER IMPLANT RTS SZ1-4,10041175,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,2434.00,730.20,944.39,2068.90,,,,,,,,,,,,,,,,,,,,944.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1034.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1825.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1217.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2068.90,,,percent of total billed charges,,,1095.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER IMPLANT RTS SZ1-4,10041175,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,2434.00,730.20,1034.45,2068.90,,,,,,,,,,,,,service not payable,,,,,,,1227.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1034.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1825.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1217.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1825.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2068.90,,,percent of total billed charges,,,1119.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT FLX 1ST MPJ W GRMTS SZ 2 X_M30 SE020 X_IN2,10041177,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT FLX 1ST MPJ W GRMTS SZ 2 X_M30 SE020 X_IN2,10041177,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE UHMWPE SZ3-4 EF 17MM,10043084,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7482.00,2244.60,2903.02,6359.70,,3666.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3142.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2903.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3179.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5611.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3741.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6359.70,,,percent of total billed charges,,,3366.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE UHMWPE SZ3-4 EF 17MM,10043084,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7482.00,2244.60,3142.44,6359.70,,3666.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3142.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3773.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3179.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5611.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3741.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5611.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6359.70,,,percent of total billed charges,,,3441.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U8 3X22X130,10043085,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1012.00,303.60,430.10,860.20,,625.42,,,percent of total billed charges,,,,,,,,service not payable,493.86,,,percent of total billed charges,,,510.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,430.10,,,percent of total billed charges,,,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,506.0,,,percent of total billed charges,,,,,,,,service not payable,759.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,860.20,,,percent of total billed charges,,,465.52,,,percent of total billed charges,,,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR MULTIFIX ULTRA 5.5MM,10043086,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1907.00,572.10,739.92,1620.95,,,,,,,,,,,,,,,,,,,,739.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,810.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1430.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,953.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1620.95,,,percent of total billed charges,,,858.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR MULTIFIX ULTRA 5.5MM,10043086,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1907.00,572.10,810.48,1620.95,,,,,,,,,,,,,service not payable,,,,,,,961.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,810.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1430.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,953.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1430.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1620.95,,,percent of total billed charges,,,877.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 44MM ID 64MM OD 20DEG X_71331108,10043087,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 44MM ID 64MM OD 20DEG X_71331108,10043087,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 44MM X_71342344 X_SMITH NEPHEW,10043088,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 44MM X_71342344 X_SMITH NEPHEW,10043088,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK LP TI 4.5X30MM,10043089,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK LP TI 4.5X30MM,10043089,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 4.5X38MM X_AR-5845L-38 X_ARTHREX INC,10043090,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 4.5X38MM X_AR-5845L-38 X_ARTHREX INC,10043090,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 4.5X50MM X_AR-8545L-50 X_ARTHREX INC,10043091,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 4.5X50MM X_AR-8545L-50 X_ARTHREX INC,10043091,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT FIXATION SLOTTED 5MM,10043092,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT FIXATION SLOTTED 5MM,10043092,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TELESCOPIC 250MM LG X_100103 X_SMITH NEPHEW,10043094,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,43.00,12.90,16.68,36.55,,,,,,,,,,,,,,,,,,,,16.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.55,,,percent of total billed charges,,,19.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TELESCOPIC 250MM LG X_100103 X_SMITH NEPHEW,10043094,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,43.00,12.90,18.27,36.55,,,,,,,,,,,,,service not payable,,,,,,,21.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36.55,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH TOUR GD 7.0X10X45X60X1 X_TG0704517 X_MEDTRO,10043095,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER FOR 6.0MM SCREW 10.0MM X_663201 X_STRYKER O,10043096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER FOR 6.0MM SCREW 10.0MM X_663201 X_STRYKER O,10043096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 6.0X40MM X_663240 X_STRYKER ORTHOP,10043097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 6.0X40MM X_663240 X_STRYKER ORTHOP,10043097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM OMNI EON 132D SZ6 30X120 X_6098-0630 X_STRYKE,10043098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM OMNI EON 132D SZ6 30X120 X_6098-0630 X_STRYKE,10043098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER KIT QUATTRO X_8700-0791-01 X_352220,10043186,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,4363.00,1308.90,1854.28,3708.55,,2696.33,,,percent of total billed charges,,,,,,,,service not payable,2129.14,,,percent of total billed charges,,,2200.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1854.28,,,percent of total billed charges,,,,,,,,,3272.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2181.5,,,percent of total billed charges,,,,,,,,service not payable,3272.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3708.55,,,percent of total billed charges,,,2006.98,,,percent of total billed charges,,,,,,,,,2835.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2835.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER KIT QUATTRO X_8700-0791-01 X_352220,10043187,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,4235.00,1270.50,1799.88,3599.75,,2617.23,,,percent of total billed charges,,,,,,,,service not payable,2066.68,,,percent of total billed charges,,,2136.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1799.88,,,percent of total billed charges,,,,,,,,,3176.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2117.5,,,percent of total billed charges,,,,,,,,service not payable,3176.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3599.75,,,percent of total billed charges,,,1948.10,,,percent of total billed charges,,,,,,,,,2752.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2752.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER IVTM SOLEX7 X_8700-0793-01 X_352221,10043196,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,3970.00,1191.00,1687.25,3374.5,,2453.46,,,percent of total billed charges,,,,,,,,service not payable,1937.36,,,percent of total billed charges,,,2002.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1687.25,,,percent of total billed charges,,,,,,,,,2977.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1985.0,,,percent of total billed charges,,,,,,,,service not payable,2977.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3374.5,,,percent of total billed charges,,,1826.2,,,percent of total billed charges,,,,,,,,,2580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CROSSLINK CONNECTOR 5.5MM X_124.986 X_GLOBUS,10043760,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CROSSLINK CONNECTOR 5.5MM X_124.986 X_GLOBUS,10043760,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXETER CENTRALISER X_0920-2-920 X_STRYKER,10043762,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXETER CENTRALISER X_0920-2-920 X_STRYKER,10043762,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ3 10MM,10043763,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ3 10MM,10043763,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ3 RT,10043764,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ3 RT,10043764,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS MICRA TRANS CATH PACING,10043765,CDM,0278,RC,C1786,HCPCS,,,,,,inpatient,facility,,,35242.00,10572.60,13673.90,29955.70,,17268.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14801.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,13673.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14977.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26431.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17621.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29955.70,,,percent of total billed charges,,,15858.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS MICRA TRANS CATH PACING,10043765,CDM,0278,RC,C1786,HCPCS,,,,,,outpatient,facility,,,35242.00,10572.60,14801.64,29955.70,,17268.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14801.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,17776.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14977.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26431.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17621.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26431.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29955.70,,,percent of total billed charges,,,16211.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U8 3.5X22X130,10043768,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1012.00,303.60,430.10,860.20,,625.42,,,percent of total billed charges,,,,,,,,service not payable,493.86,,,percent of total billed charges,,,510.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,430.10,,,percent of total billed charges,,,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,506.0,,,percent of total billed charges,,,,,,,,service not payable,759.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,860.20,,,percent of total billed charges,,,465.52,,,percent of total billed charges,,,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD NEURO SPINAL LINEAR8 55CM,10043836,CDM,0278,RC,C1883,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD NEURO SPINAL LINEAR8 55CM,10043836,CDM,0278,RC,C1883,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD NEURO SPNL LINEAR3-6 70CM,10043837,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD NEURO SPNL LINEAR3-6 70CM,10043837,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 7X14X30 8DEG X_5274308 X_NUVASIVE,10043839,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,18686.00,5605.80,7250.17,15883.1,,9156.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7848.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7250.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7941.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14014.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9343.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15883.1,,,percent of total billed charges,,,8408.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 7X14X30 8DEG X_5274308 X_NUVASIVE,10043839,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,18686.00,5605.80,7848.12,15883.1,,9156.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7848.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9425.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7941.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14014.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9343.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14014.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15883.1,,,percent of total billed charges,,,8595.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB ALD 8H 3.5X123MM RT X_71800708 X_SMITH N,10043841,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3877.00,1163.10,1504.28,3295.45,,,,,,,,,,,,,,,,,,,,1504.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1647.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2907.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1938.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3295.45,,,percent of total billed charges,,,1744.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB ALD 8H 3.5X123MM RT X_71800708 X_SMITH N,10043841,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3877.00,1163.10,1647.72,3295.45,,,,,,,,,,,,,service not payable,,,,,,,1955.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1647.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2907.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1938.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2907.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3295.45,,,percent of total billed charges,,,1783.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK LP TI 3X22MM VAR,10044100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK LP TI 3X22MM VAR,10044100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL MIDFOOT 3MM STRL,10044101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL MIDFOOT 3MM STRL,10044101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB AP PS SZ4 15MM,10044103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB AP PS SZ4 15MM,10044103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y-SHAPE LK 8H,10044104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,791.00,237.30,306.91,672.35,,,,,,,,,,,,,,,,,,,,306.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,593.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,395.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.35,,,percent of total billed charges,,,355.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y-SHAPE LK 8H,10044104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,791.00,237.30,336.18,672.35,,,,,,,,,,,,,service not payable,,,,,,,398.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,336.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,593.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,395.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,593.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,672.35,,,percent of total billed charges,,,363.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON DILAT URS 18F 6MMX4CM X_BURS0604 X_OLYMPUS,10044105,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1000.00,300.00,425.0,850.0,,618.0,,,percent of total billed charges,,,,,,,,service not payable,488.0,,,percent of total billed charges,,,504.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,425.0,,,percent of total billed charges,,,,,,,,,750.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,500.0,,,percent of total billed charges,,,,,,,,service not payable,750.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,850.0,,,percent of total billed charges,,,460.0,,,percent of total billed charges,,,,,,,,,650.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,650.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH PNCL INTRO 10CM 9F,10044106,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL WRIST HOOK 5H,10044109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2601.00,780.30,1009.19,2210.85,,,,,,,,,,,,,,,,,,,,1009.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2210.85,,,percent of total billed charges,,,1170.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL WRIST HOOK 5H,10044109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,,,,,,,,,,,,service not payable,,,,,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PLUG 4D 7.0MM,10044110,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PLUG 4D 7.0MM,10044110,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PLUG 4D 6.0MM,10044111,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PLUG 4D 6.0MM,10044111,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3.0X30MM,10044113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1078.00,323.40,418.26,916.30,,,,,,,,,,,,,,,,,,,,418.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916.30,,,percent of total billed charges,,,485.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3.0X30MM,10044113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1078.00,323.40,458.15,916.30,,,,,,,,,,,,,service not payable,,,,,,,543.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,808.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,916.30,,,percent of total billed charges,,,495.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALL FLASH OSTIAL 3.5X8,10044114,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,3639.00,1091.70,1546.58,3093.15,,2248.90,,,percent of total billed charges,,,,,,,,service not payable,1775.83,,,percent of total billed charges,,,1835.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1546.58,,,percent of total billed charges,,,,,,,,,2729.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1819.5,,,percent of total billed charges,,,,,,,,service not payable,2729.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3093.15,,,percent of total billed charges,,,1673.94,,,percent of total billed charges,,,,,,,,,2365.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2365.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT PROX COMP THORACIC X_VAMF4040C150TU X_,10044236,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT PROX COMP THORACIC X_VAMF4040C150TU X_,10044236,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT DISTAL COMP THORACIC X_VAMC4444C150TU,10044237,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,58172.00,17451.60,22570.74,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,22570.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49446.20,,,percent of total billed charges,,,26177.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT DISTAL COMP THORACIC X_VAMC4444C150TU,10044237,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,58172.00,17451.60,24432.24,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,29341.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,49446.20,,,percent of total billed charges,,,26759.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT DISTAL COMP THORACIC X_VAMC4646C150TU,10044238,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,58172.00,17451.60,22570.74,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,22570.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49446.20,,,percent of total billed charges,,,26177.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT DISTAL COMP THORACIC X_VAMC4646C150TU,10044238,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,58172.00,17451.60,24432.24,49446.20,,28504.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24432.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,29341.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24723.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,43629.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29086.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,43629.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,49446.20,,,percent of total billed charges,,,26759.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Introducer Sheath Orange Hub 7F 18G 25Cm X_Merit M,10044239,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,168.00,50.40,71.40,142.80,,103.82,,,percent of total billed charges,,,,,,,,service not payable,81.98,,,percent of total billed charges,,,84.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,71.40,,,percent of total billed charges,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,84.0,,,percent of total billed charges,,,,,,,,service not payable,126.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,142.80,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,109.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 2.3X26MM X_50-330-26-09 X_KLS MARTIN L P,10044241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,349.00,104.70,135.41,296.65,,,,,,,,,,,,,,,,,,,,135.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,157.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 2.3X26MM X_50-330-26-09 X_KLS MARTIN L P,10044241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,349.00,104.70,148.32,296.65,,,,,,,,,,,,,service not payable,,,,,,,176.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,296.65,,,percent of total billed charges,,,160.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 22FRX28CM,10044243,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.5X12MM,10044619,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.5X12MM,10044619,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.5X15MM,10044620,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.5X15MM,10044620,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.5X18MM,10044621,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.5X18MM,10044621,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.5X22MM,10044622,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.5X22MM,10044622,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.5X26MM,10044623,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.5X26MM,10044623,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.5X30MM,10044624,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.5X30MM,10044624,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 5.0X12MM,10044625,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 5.0X12MM,10044625,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 5.0X15MM X_RONYX50015UX X_MEDTRO,10044626,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 5.0X15MM X_RONYX50015UX X_MEDTRO,10044626,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 5.0X18MM,10044627,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 5.0X18MM,10044627,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 5.0X22MM,10044628,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 5.0X22MM,10044628,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 5.0X26MM,10044629,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 5.0X26MM,10044629,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 5.0X30MM,10044630,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4491.00,1347.30,1742.51,3817.35,,,,,,,,,,,,,,,,,,,,1742.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3817.35,,,percent of total billed charges,,,2020.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 5.0X30MM,10044630,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4491.00,1347.30,1908.68,3817.35,,,,,,,,,,,,,service not payable,,,,,,,2265.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1908.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3368.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3368.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3817.35,,,percent of total billed charges,,,2065.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CEM AS VEGA SZ3 LT,10046097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CEM AS VEGA SZ3 LT,10046097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB PLATEAU CMT 65X43MM,10046098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB PLATEAU CMT 65X43MM,10046098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDE SURFACE PS T1/T1 10MM,10046099,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDE SURFACE PS T1/T1 10MM,10046099,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CUSTOM TI MANDIBLE,10046100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,27538.00,8261.40,10684.74,23407.30,,13493.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11565.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10684.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11703.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20653.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13769.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23407.30,,,percent of total billed charges,,,12392.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CUSTOM TI MANDIBLE,10046100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,27538.00,8261.40,11565.96,23407.30,,13493.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11565.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13890.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11703.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20653.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13769.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20653.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,23407.30,,,percent of total billed charges,,,12667.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE HP MUSTANG 5.0X200,10046101,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE PLTNM ST 0.014X300,10046102,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,434.00,130.20,184.45,368.90,,268.21,,,percent of total billed charges,,,,,,,,service not payable,211.79,,,percent of total billed charges,,,218.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,184.45,,,percent of total billed charges,,,,,,,,,325.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,217.0,,,percent of total billed charges,,,,,,,,service not payable,325.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,368.90,,,percent of total billed charges,,,199.64,,,percent of total billed charges,,,,,,,,,282.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,282.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SEALANT SURG PREVELEAK,10046107,CDM,0623,RC,A6250,HCPCS,,,,,,outpatient,facility,,,2736.00,820.80,1162.8,2325.60,,1690.85,,,percent of total billed charges,,,,,,,,service not payable,1335.17,,,percent of total billed charges,,,1380.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1162.8,,,percent of total billed charges,,,,,,,,,2052.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1368.0,,,percent of total billed charges,,,,,,,,service not payable,2052.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2325.60,,,percent of total billed charges,,,1258.56,,,percent of total billed charges,,,,,,,,,1778.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1778.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON VAGINAL PACK SYSTEM X_ALA-45 X_RADIADYNE L,10046111,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,384.00,115.20,148.99,326.40,,,,,,,,,,,,,,,,,,,,148.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,172.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON VAGINAL PACK SYSTEM X_ALA-45 X_RADIADYNE L,10046111,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,,,,,,,,,,,,service not payable,,,,,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT DBM PUTTY 2.5CC X_3102-1002 X_STRYKER OR,10046114,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,3082.00,924.60,1195.82,2619.70,,,,,,,,,,,,,,,,,,,,1195.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2311.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1541.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2619.70,,,percent of total billed charges,,,1386.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT DBM PUTTY 2.5CC X_3102-1002 X_STRYKER OR,10046114,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,3082.00,924.60,1309.85,2619.70,,,,,,,,,,,,,service not payable,,,,,,,1554.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1309.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2311.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1541.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2311.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2619.70,,,percent of total billed charges,,,1417.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT DBM PUTTY 2.5CC X_3102-1002 X_STRYKER OR,10046114,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,3082.00,924.60,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DIL AERIS 16MM,10046248,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT INFINITY POLY SZ2 8MM X_33652208 X_WRIGHT M,10046249,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT INFINITY POLY SZ2 8MM X_33652208 X_WRIGHT M,10046249,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT CNTRA LEG 20MMX9.5CM,10046250,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,14136.00,4240.80,5484.77,12015.6,,6926.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5937.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5484.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6007.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10602.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7068.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12015.6,,,percent of total billed charges,,,6361.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT CNTRA LEG 20MMX9.5CM,10046250,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,14136.00,4240.80,5937.12,12015.6,,6926.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5937.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7130.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6007.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10602.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7068.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10602.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12015.6,,,percent of total billed charges,,,6502.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE COMP CENTRAL 25X6.5,10046251,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,437.00,131.10,169.56,371.45,,,,,,,,,,,,,,,,,,,,169.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,196.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE COMP CENTRAL 25X6.5,10046251,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,,,,,,,,,,,,service not payable,,,,,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN LK KNEE TIB PRIMARY AMK,10046252,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2590.00,777.00,1004.92,2201.5,,,,,,,,,,,,,,,,,,,,1004.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1100.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1942.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2201.5,,,percent of total billed charges,,,1165.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN LK KNEE TIB PRIMARY AMK,10046252,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2590.00,777.00,1100.75,2201.5,,,,,,,,,,,,,service not payable,,,,,,,1306.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1100.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1942.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1942.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2201.5,,,percent of total billed charges,,,1191.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP LK KNEE TIB AMK,10046253,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1866.00,559.80,724.01,1586.10,,,,,,,,,,,,,,,,,,,,724.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,793.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,933.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1586.10,,,percent of total billed charges,,,839.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LK KNEE TIB AMK,10046253,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1866.00,559.80,793.05,1586.10,,,,,,,,,,,,,service not payable,,,,,,,941.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,793.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1399.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,933.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1399.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1586.10,,,percent of total billed charges,,,858.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB AMK SZ4 12MM,10046254,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6233.00,1869.90,2418.40,5298.05,,3054.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2617.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2418.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2649.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4674.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3116.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5298.05,,,percent of total billed charges,,,2804.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB AMK SZ4 12MM,10046254,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6233.00,1869.90,2617.86,5298.05,,3054.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2617.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3143.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2649.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4674.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3116.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4674.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5298.05,,,percent of total billed charges,,,2867.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI 40MM X_14355040 X_NUVASIVE,10046255,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI 40MM X_14355040 X_NUVASIVE,10046255,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COLLAR CERV O FIRM FOAM LG,10046256,CDM,0274,RC,L0120,HCPCS,,,,,,inpatient,facility,,,61.00,18.30,23.67,51.85,,,,,,,,,,,,,,,,,,,,23.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.85,,,percent of total billed charges,,,27.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAR CERV O FIRM FOAM LG,10046256,CDM,0274,RC,L0120,HCPCS,,,,,,outpatient,facility,,,61.00,18.30,25.93,90.11,,,,,,,,39.23,,,fee schedule,,,,,,,,,30.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,82.53,,,fee schedule,,,27.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",40.01,,,fee schedule,,,90.11,,,fee schedule,,,,,,,,,39.23,,,fee schedule,,,,,,,,,25.93,,,percent of total billed charges,,Paid in addition to outpatient services ,81.33,,,fee schedule,,,45.75,,,percent of total billed charges,,,39.23,,,fee schedule,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,30.5,,,percent of total billed charges,,Paid in addition to outpatient services ,39.23,,,fee schedule,,,45.75,,,percent of total billed charges,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,,,,,,,51.85,,,percent of total billed charges,,,28.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,39.63,,,fee schedule,,,,,,,,
DEVICE VALITUDE X4/ET X_8V4J X_BOSTON SCIENTIFIC C,10046258,CDM,0278,RC,C2621,HCPCS,,,,,,inpatient,facility,,,24226.00,7267.80,9399.69,20592.10,,11870.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10174.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9399.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10296.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20592.10,,,percent of total billed charges,,,10901.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE VALITUDE X4/ET X_8V4J X_BOSTON SCIENTIFIC C,10046258,CDM,0278,RC,C2621,HCPCS,,,,,,outpatient,facility,,,24226.00,7267.80,10174.92,20592.10,,11870.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10174.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12219.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10296.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,20592.10,,,percent of total billed charges,,,11143.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATFORM CM BLOCK 2X6.25X0.8CM,10046259,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5422.00,1626.60,2103.74,4608.70,,2656.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2277.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2103.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2304.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4066.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2711.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4608.70,,,percent of total billed charges,,,2439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATFORM CM BLOCK 2X6.25X0.8CM,10046259,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5422.00,1626.60,2277.24,4608.70,,2656.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2277.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2734.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2304.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4066.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2711.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4066.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4608.70,,,percent of total billed charges,,,2494.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER GENERATOR ELUNA 8 DR-T PROMRI X_394969 X,10046389,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,12295.00,3688.50,4770.46,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.90,,,percent of total billed charges,,Paid in addition to inpatient services ,4770.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10450.75,,,percent of total billed charges,,,5532.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER GENERATOR ELUNA 8 DR-T PROMRI X_394969 X,10046389,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,12295.00,3688.50,5163.90,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.90,,,percent of total billed charges,,Paid in addition to outpatient services ,6201.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10450.75,,,percent of total billed charges,,,5655.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD ATRIAL RT SOLIA S 45 X_377176 X_BIOTRONIK USA,10046390,CDM,0275,RC,C1898,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD ATRIAL RT SOLIA S 45 X_377176 X_BIOTRONIK USA,10046390,CDM,0275,RC,C1898,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD VENTRAL RT SOLIA S 53 X_377177 X_BIOTRONIK US,10046391,CDM,0275,RC,C1898,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD VENTRAL RT SOLIA S 53 X_377177 X_BIOTRONIK US,10046391,CDM,0275,RC,C1898,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE JR4 8F 100CM,10046635,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,266.00,79.80,113.05,226.10,,164.39,,,percent of total billed charges,,,,,,,,service not payable,129.81,,,percent of total billed charges,,,134.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,113.05,,,percent of total billed charges,,,,,,,,,199.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,133.0,,,percent of total billed charges,,,,,,,,service not payable,199.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,226.10,,,percent of total billed charges,,,122.36,,,percent of total billed charges,,,,,,,,,172.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,172.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DX COBRA2 5F 100CM,10046636,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,75.00,22.50,31.88,63.75,,46.35,,,percent of total billed charges,,,,,,,,service not payable,36.60,,,percent of total billed charges,,,37.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,31.88,,,percent of total billed charges,,,,,,,,,56.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,37.5,,,percent of total billed charges,,,,,,,,service not payable,56.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,63.75,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,48.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS SOLARA MRI QUAD CRTP,10046637,CDM,0275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,17966.00,5389.80,6970.81,15271.1,,8803.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7545.72,,,percent of total billed charges,,Paid in addition to inpatient services ,6970.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7635.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13474.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8983.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15271.1,,,percent of total billed charges,,,8084.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS SOLARA MRI QUAD CRTP,10046637,CDM,0275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,17966.00,5389.80,7545.72,15271.1,,8803.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7545.72,,,percent of total billed charges,,Paid in addition to outpatient services ,9062.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7635.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13474.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8983.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13474.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15271.1,,,percent of total billed charges,,,8264.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG VASC 0.55X12X16MM,10046638,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG VASC 0.55X12X16MM,10046638,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IMPACT 5MMX150MMX130CM,10046639,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,5607.00,1682.10,2382.97,4765.95,,3465.13,,,percent of total billed charges,,,,,,,,service not payable,2736.22,,,percent of total billed charges,,,2828.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2382.97,,,percent of total billed charges,,,,,,,,,4205.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,4205.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4765.95,,,percent of total billed charges,,,2579.22,,,percent of total billed charges,,,,,,,,,3644.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3644.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ATHERECTOMY HAWK 7.0FR,10046640,CDM,0272,RC,C1724,HCPCS,,,,,,outpatient,facility,,,11950.00,3585.00,5078.75,10157.5,,7385.10,,,percent of total billed charges,,,,,,,,service not payable,5831.60,,,percent of total billed charges,,,6027.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5078.75,,,percent of total billed charges,,,,,,,,,8962.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5975.0,,,percent of total billed charges,,,,,,,,service not payable,8962.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10157.5,,,percent of total billed charges,,,5497.0,,,percent of total billed charges,,,,,,,,,7767.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7767.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIPH 6X120X120 6F X_S-60-120-120-P6 X_ABBO,10046641,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH 6X120X120 6F X_S-60-120-120-P6 X_ABBO,10046641,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE PRTCT EMBOLIC 320CMX5MM,10046642,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,2826.73,,,percent of total billed charges,,,,,,,,service not payable,2232.11,,,percent of total billed charges,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2287.0,,,percent of total billed charges,,,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,2973.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2973.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP 11X55MM,10046644,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP 11X55MM,10046644,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CMPRS FT XL 7.0X45MM,10046645,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CMPRS FT XL 7.0X45MM,10046645,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE TROC TIP 2.4MMX9.25IN,10046646,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,99.00,29.70,42.08,84.15,,61.18,,,percent of total billed charges,,,,,,,,service not payable,48.31,,,percent of total billed charges,,,49.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.08,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,74.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,64.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,64.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INTRATHECAL X_8785 X_MEDTRONIC,10046647,CDM,0272,RC,C1755,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,675.47,,,percent of total billed charges,,,,,,,,service not payable,533.38,,,percent of total billed charges,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,710.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,710.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS ICD EMBLEM MRI,10046648,CDM,0278,RC,C1722,HCPCS,,,,,,inpatient,facility,,,70481.00,21144.30,27346.63,59908.85,,34535.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29602.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27346.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29954.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,52860.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35240.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59908.85,,,percent of total billed charges,,,31716.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS ICD EMBLEM MRI,10046648,CDM,0278,RC,C1722,HCPCS,,,,,,outpatient,facility,,,70481.00,21144.30,29602.02,59908.85,,34535.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29602.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35550.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29954.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,52860.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35240.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,52860.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59908.85,,,percent of total billed charges,,,32421.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA3 TI BLOCKER X_48145545 X_STRYKER,10046649,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA3 TI BLOCKER X_48145545 X_STRYKER,10046649,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 4.5X50MM X_481322050 X_STRYKER,10046650,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 4.5X50MM X_481322050 X_STRYKER,10046650,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF -OP visit new patient moderate level 45-59 mi,10046678,CDM,0510,RC,99204,CPT,,,,,,outpatient,facility,,,345.00,103.50,158.70,293.25,,213.21,,,percent of total billed charges,,,,,,,,service not payable,168.36,,,percent of total billed charges,,,174.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,258.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,158.70,,,percent of total billed charges,,,,,,,,,224.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,224.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF -OP visit new patient moderate level 45-59 mi,10046678,CDM,0510,RC,99204,CPT,852,EAPG,,,,outpatient,facility,,,345.00,103.50,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF -OP visit new patient moderate level 45-59 mi,10046678,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,450.00,135.00,207.0,382.5,,278.10,,,percent of total billed charges,,,,,,,,,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
BCF -OP visit new patient moderate level 45-59 mi,10046678,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,450.00,135.00,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
BCF -OP visit new patient moderate level 45-59 mi,10046678,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,450.00,135.00,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE 6H 40MM STRT UTLTY X_PLP40400 X_STRYKER ORTH,10047149,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3683.00,1104.90,1429.00,3130.55,,,,,,,,,,,,,,,,,,,,1429.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1565.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2762.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1841.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3130.55,,,percent of total billed charges,,,1657.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 6H 40MM STRT UTLTY X_PLP40400 X_STRYKER ORTH,10047149,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3683.00,1104.90,1565.27,3130.55,,,,,,,,,,,,,service not payable,,,,,,,1857.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1565.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2762.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1841.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2762.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3130.55,,,percent of total billed charges,,,1694.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE CR LGN SZ3-4 9MM,10047150,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE CR LGN SZ3-4 9MM,10047150,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE T ALIF 6X42X30MM 15DEG X_6953615 X_NUVASIVE,10047151,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE T ALIF 6X42X30MM 15DEG X_6953615 X_NUVASIVE,10047151,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BRIGADE LORDOTIC 40MM X_7880040 X_NUVASIVE,10047152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BRIGADE LORDOTIC 40MM X_7880040 X_NUVASIVE,10047152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG MAND 4X4 X_50-750-08 X_KLS MARTIN L P,10047153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2896.00,868.80,1123.65,2461.60,,,,,,,,,,,,,,,,,,,,1123.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1230.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2172.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1448.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.60,,,percent of total billed charges,,,1303.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG MAND 4X4 X_50-750-08 X_KLS MARTIN L P,10047153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2896.00,868.80,1230.8,2461.60,,,,,,,,,,,,,service not payable,,,,,,,1460.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1230.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2172.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1448.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2172.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2461.60,,,percent of total billed charges,,,1332.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB STBplus  SZ2.5 15MM,10047154,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7364.00,2209.20,2857.23,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2857.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6259.40,,,percent of total billed charges,,,3313.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB STBplus  SZ2.5 15MM,10047154,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7364.00,2209.20,3092.88,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3714.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6259.40,,,percent of total billed charges,,,3387.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT POST FEM SIG SZ2.5 8MM,10047155,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT POST FEM SIG SZ2.5 8MM,10047155,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR MRI 7.5AH IPG X_3662ANS X_ST JUDE,10047156,CDM,0278,RC,C1767,HCPCS,,,,,,inpatient,facility,,,50703.00,15210.90,19672.76,43097.55,,24844.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21295.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,19672.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21548.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38027.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43097.55,,,percent of total billed charges,,,22816.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR MRI 7.5AH IPG X_3662ANS X_ST JUDE,10047156,CDM,0278,RC,C1767,HCPCS,,,,,,outpatient,facility,,,50703.00,15210.90,21295.26,43097.55,,24844.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21295.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,25574.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21548.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38027.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38027.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43097.55,,,percent of total billed charges,,,23323.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 9MM,10047377,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 9MM,10047377,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HMRL VERSADL 42X18X46MM,10047381,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4380.00,1314.00,1699.44,3723.0,,,,,,,,,,,,,,,,,,,,1699.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3723.0,,,percent of total billed charges,,,1971.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HMRL VERSADL 42X18X46MM,10047381,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4380.00,1314.00,1861.5,3723.0,,,,,,,,,,,,,service not payable,,,,,,,2209.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3723.0,,,percent of total billed charges,,,2014.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 10MM,10047382,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 10MM,10047382,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP SYNTHETIC CARTILAGE 10MM,10048213,CDM,0278,RC,L8641,HCPCS,,,,,,inpatient,facility,,,2237.00,671.10,867.96,1901.45,,,,,,,,,,,,,,,,,,,,867.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,950.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1677.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1118.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1901.45,,,percent of total billed charges,,,1006.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP SYNTHETIC CARTILAGE 10MM,10048213,CDM,0278,RC,L8641,HCPCS,,,,,,outpatient,facility,,,2237.00,671.10,950.73,1901.45,,,,,,,,,,,,,service not payable,,,,,,,1128.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,950.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1677.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1118.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1677.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1901.45,,,percent of total billed charges,,,1029.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE NON-THREADED 2MM X_PNN-02S X_CARTIVA,10048214,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,446.00,133.80,173.05,379.10,,,,,,,,,,,,,,,,,,,,173.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,334.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,223.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.10,,,percent of total billed charges,,,200.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE NON-THREADED 2MM X_PNN-02S X_CARTIVA,10048214,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,446.00,133.80,189.55,379.10,,,,,,,,,,,,,service not payable,,,,,,,224.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,334.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,223.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,334.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,379.10,,,percent of total billed charges,,,205.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANN MINI 16X3.0MM,10048217,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN MINI 16X3.0MM,10048217,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANN MINI 36X3.0MM,10048218,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1842.00,552.60,714.70,1565.7,,,,,,,,,,,,,,,,,,,,714.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1565.7,,,percent of total billed charges,,,828.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN MINI 36X3.0MM,10048218,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1842.00,552.60,782.85,1565.7,,,,,,,,,,,,,service not payable,,,,,,,929.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1565.7,,,percent of total billed charges,,,847.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANN HDLESS22X3.0MM,10048219,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2566.00,769.80,995.61,2181.10,,,,,,,,,,,,,,,,,,,,995.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.10,,,percent of total billed charges,,,1154.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN HDLESS22X3.0MM,10048219,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2566.00,769.80,1090.55,2181.10,,,,,,,,,,,,,service not payable,,,,,,,1294.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2181.10,,,percent of total billed charges,,,1180.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANCHOR MTP LONG LS X_PLP10461 X_STRYKER,10048220,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3699.00,1109.70,1435.21,3144.15,,,,,,,,,,,,,,,,,,,,1435.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1572.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2774.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1849.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3144.15,,,percent of total billed charges,,,1664.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANCHOR MTP LONG LS X_PLP10461 X_STRYKER,10048220,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3699.00,1109.70,1572.08,3144.15,,,,,,,,,,,,,service not payable,,,,,,,1865.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1572.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2774.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1849.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2774.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3144.15,,,percent of total billed charges,,,1701.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
L/S Spinal Inj,10050327,CDM,0761,RC,62323,CPT,,,,,,outpatient,facility,,,2202.00,660.60,118.0,1871.7,,1360.84,,,percent of total billed charges,,,,,,,,,1074.58,,,percent of total billed charges,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
L/S Spinal Inj,10050327,CDM,0761,RC,62323,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
L/S Spinal Inj,10050327,CDM,0761,RC,62323,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
L/S Spinal Inj,10050328,CDM,0761,RC,62323,CPT,,,,,,outpatient,facility,,,2202.00,660.60,118.0,1871.7,,1360.84,,,percent of total billed charges,,,,,,,,,1074.58,,,percent of total billed charges,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
L/S Spinal Inj,10050328,CDM,0761,RC,62323,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
L/S Spinal Inj,10050328,CDM,0761,RC,62323,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW BIOSURE BONE 10X20MM,10050347,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1342.00,402.60,520.70,1140.7,,,,,,,,,,,,,,,,,,,,520.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.7,,,percent of total billed charges,,,603.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIOSURE BONE 10X20MM,10050347,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1342.00,402.60,570.35,1140.7,,,,,,,,,,,,,service not payable,,,,,,,676.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,617.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW QUICK FIX 2.0X8MM X_71102285 X_SMITH NEPHEW,10050348,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1037.00,311.10,402.36,881.45,,,,,,,,,,,,,,,,,,,,402.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,440.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,777.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,518.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,881.45,,,percent of total billed charges,,,466.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW QUICK FIX 2.0X8MM X_71102285 X_SMITH NEPHEW,10050348,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1037.00,311.10,440.72,881.45,,,,,,,,,,,,,service not payable,,,,,,,523.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,440.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,777.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,518.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,777.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,881.45,,,percent of total billed charges,,,477.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT LAT FEMORAL CHONDYL X_172127-002 X_JOINT,10050349,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,37453.00,11235.90,14531.76,31835.05,,18351.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15730.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14531.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15917.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28089.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18726.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31835.05,,,percent of total billed charges,,,16853.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT LAT FEMORAL CHONDYL X_172127-002 X_JOINT,10050349,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,37453.00,11235.90,15730.26,31835.05,,18351.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15730.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18891.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15917.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28089.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18726.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28089.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31835.05,,,percent of total billed charges,,,17228.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH TOUR GD STEERABLE 6.5X17X45 X_TG0654517 X_A,10050350,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CRS SZ 7,10050351,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CRS SZ 7,10050351,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON VIATRAC 14 PLUS X_1008191-30 X_ABBOTT VASC,10050352,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CRS SZ 3,10050353,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11606.00,3481.80,4503.13,9865.10,,5686.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4874.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4503.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4932.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8704.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5803.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9865.10,,,percent of total billed charges,,,5222.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CRS SZ 3,10050353,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11606.00,3481.80,4874.52,9865.10,,5686.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4874.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5854.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4932.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8704.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5803.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8704.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9865.10,,,percent of total billed charges,,,5338.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR NAR CEM SZ4 RT X_1504-00-224 X_DEPUY,10050354,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR NAR CEM SZ4 RT X_1504-00-224 X_DEPUY,10050354,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ7 6MM X_1516-20-706 X_DEPUY,10050355,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ7 6MM X_1516-20-706 X_DEPUY,10050355,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 13MM LT X_71420252 X_SMITH NEPHEW,10050356,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 13MM LT X_71420252 X_SMITH NEPHEW,10050356,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM SOLARA MRI QUAD MMAM X_SOLARAMRIQDMMQM X_ME,10050357,CDM,0278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,25069.00,7520.70,9726.77,21308.65,,12283.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10528.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9726.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10654.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12534.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21308.65,,,percent of total billed charges,,,11281.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM SOLARA MRI QUAD MMAM X_SOLARAMRIQDMMQM X_ME,10050357,CDM,0278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,25069.00,7520.70,10528.98,21308.65,,12283.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10528.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12644.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10654.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18801.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12534.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18801.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21308.65,,,percent of total billed charges,,,11531.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT KNEE 18X130MM X_1988-16-18 X_ZIMMER BIOME,10050543,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3806.00,1141.80,1476.73,3235.10,,,,,,,,,,,,,,,,,,,,1476.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3235.10,,,percent of total billed charges,,,1712.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT KNEE 18X130MM X_1988-16-18 X_ZIMMER BIOME,10050543,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3806.00,1141.80,1617.55,3235.10,,,,,,,,,,,,,service not payable,,,,,,,1919.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3235.10,,,percent of total billed charges,,,1750.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT STRT 15X30MM X_5988-12-15 X_ZIMMER BIOMET,10050544,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3975.00,1192.50,1542.3,3378.75,,,,,,,,,,,,,,,,,,,,1542.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1689.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2981.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1987.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3378.75,,,percent of total billed charges,,,1788.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT STRT 15X30MM X_5988-12-15 X_ZIMMER BIOMET,10050544,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3975.00,1192.50,1689.38,3378.75,,,,,,,,,,,,,service not payable,,,,,,,2004.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1689.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2981.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1987.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2981.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3378.75,,,percent of total billed charges,,,1828.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS CL 11.5D X_Z9002-11.5 X_ABBOTT,10050545,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,1126.00,337.80,436.89,957.10,,,,,,,,,,,,,,,,,,,,436.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,844.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,563.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.10,,,percent of total billed charges,,,506.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS CL 11.5D X_Z9002-11.5 X_ABBOTT,10050545,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,1126.00,337.80,478.55,957.10,,,,,,,,,,,,,service not payable,,,,,,,567.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,844.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,563.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,844.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,957.10,,,percent of total billed charges,,,517.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREWS BIASED ANG 3.5X12MM X_48557312 X_STRYKER SP,10050547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2755.00,826.50,1068.94,2341.75,,,,,,,,,,,,,,,,,,,,1068.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.75,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREWS BIASED ANG 3.5X12MM X_48557312 X_STRYKER SP,10050547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2755.00,826.50,1170.88,2341.75,,,,,,,,,,,,,service not payable,,,,,,,1389.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1170.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2066.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1377.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2066.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2341.75,,,percent of total billed charges,,,1267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO DBM PLUS 10ML,10050548,CDM,0278,RC,C1780,HCPCS,,,,,,inpatient,facility,,,6882.00,2064.60,2670.22,5849.70,,3372.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2890.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2670.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2924.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3441.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5849.70,,,percent of total billed charges,,,3096.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY BIO DBM PLUS 10ML,10050548,CDM,0278,RC,C1780,HCPCS,,,,,,outpatient,facility,,,6882.00,2064.60,2890.44,5849.70,,3372.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2890.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3471.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2924.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5161.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3441.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5161.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5849.70,,,percent of total billed charges,,,3165.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLING HIGH BACK MED X_3525915-2 X_330807,10051494,CDM,0271,RC,A4565,HCPCS,,,,,,outpatient,facility,,,190.00,57.00,80.75,161.5,,117.42,,,percent of total billed charges,,,,,,,,service not payable,92.72,,,percent of total billed charges,,,95.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.75,,,percent of total billed charges,,,,,,,,,142.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.0,,,percent of total billed charges,,,,,,,,service not payable,142.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,161.5,,,percent of total billed charges,,,87.40,,,percent of total billed charges,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL PLAT CR/PS AS COL SZ 0 X_NN070Z X_AESCULAP,10051504,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL PLAT CR/PS AS COL SZ 0 X_NN070Z X_AESCULAP,10051504,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR AS COL NARROW X_NN811Z X_AESCULAP,10051505,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR AS COL NARROW X_NN811Z X_AESCULAP,10051505,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE COL CR DD GLID 0 10MM X_ NN200 X_AESCULAP,10051506,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE COL CR DD GLID 0 10MM X_ NN200 X_AESCULAP,10051506,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEM 48X23MM XZD LM/RL X_00584201401 X_SMITH,10051516,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEM 48X23MM XZD LM/RL X_00584201401 X_SMITH,10051516,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB 25X44MM SZ2 LM/RL X_00584200201 X_SMITH,10051517,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB 25X44MM SZ2 LM/RL X_00584200201 X_SMITH,10051517,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ARTICULAR FEM 10MM SZ2 X_00584202210 X_SMITH NEPHE,10051518,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTICULAR FEM 10MM SZ2 X_00584202210 X_SMITH NEPHE,10051518,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY EXPND SS 9.0X37MM X_PXB35-09-37-080,10051520,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3478.00,1043.40,1349.46,2956.30,,,,,,,,,,,,,,,,,,,,1349.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1478.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2608.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1739.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2956.30,,,percent of total billed charges,,,1565.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY EXPND SS 9.0X37MM X_PXB35-09-37-080,10051520,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3478.00,1043.40,1478.15,2956.30,,,,,,,,,,,,,service not payable,,,,,,,1754.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1478.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2608.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1739.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2608.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2956.30,,,percent of total billed charges,,,1599.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANGLE LOCK 4X4 X_50-758-08-09 X_KLS MARTIN L,10051527,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2896.00,868.80,1123.65,2461.60,,,,,,,,,,,,,,,,,,,,1123.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1230.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2172.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1448.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.60,,,percent of total billed charges,,,1303.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANGLE LOCK 4X4 X_50-758-08-09 X_KLS MARTIN L,10051527,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2896.00,868.80,1230.8,2461.60,,,,,,,,,,,,,service not payable,,,,,,,1460.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1230.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2172.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1448.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2172.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2461.60,,,percent of total billed charges,,,1332.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DIST TPR RCLM DIST 20X190,10051528,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13979.00,4193.70,5423.85,11882.15,,6849.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5871.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5423.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5941.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10484.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6989.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11882.15,,,percent of total billed charges,,,6290.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DIST TPR RCLM DIST 20X190,10051528,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13979.00,4193.70,5871.18,11882.15,,6849.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5871.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7051.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5941.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10484.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6989.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10484.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11882.15,,,percent of total billed charges,,,6430.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SUP DECRSD 7H 88MM X_628027 X_STRYKER ORTHOP,10071413,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4188.00,1256.40,1624.94,3559.80,,,,,,,,,,,,,,,,,,,,1624.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1779.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3141.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2094.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3559.80,,,percent of total billed charges,,,1884.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SUP DECRSD 7H 88MM X_628027 X_STRYKER ORTHOP,10071413,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4188.00,1256.40,1779.90,3559.80,,,,,,,,,,,,,service not payable,,,,,,,2112.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1779.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3141.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2094.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3141.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3559.80,,,percent of total billed charges,,,1926.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP CANN 4X46MM X_663046 X_STRYKER ORTHOPAE,10071414,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6079.00,1823.70,2358.65,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2358.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5167.15,,,percent of total billed charges,,,2735.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP CANN 4X46MM X_663046 X_STRYKER ORTHOPAE,10071414,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6079.00,1823.70,2553.18,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3066.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5167.15,,,percent of total billed charges,,,2796.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT WRIST THUMB EXT RT SM,10071417,CDM,0274,RC,L3809,HCPCS,,,,,,inpatient,facility,,,126.00,37.80,48.89,107.10,,,,,,,,,,,,,,,,,,,,48.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.10,,,percent of total billed charges,,,56.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THUMB EXT RT SM,10071417,CDM,0274,RC,L3809,HCPCS,,,,,,outpatient,facility,,,126.00,37.80,53.55,284.76,,,,,,,,123.98,,,fee schedule,,,,,,,,,63.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,260.82,,,fee schedule,,,126.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.46,,,fee schedule,,,284.76,,,fee schedule,,,,,,,,,123.98,,,fee schedule,,,,,,,,,53.55,,,percent of total billed charges,,Paid in addition to outpatient services ,257.04,,,fee schedule,,,94.5,,,percent of total billed charges,,,123.98,,,fee schedule,,,126.0,,,fee schedule,,,126.46,,,fee schedule,,,63.0,,,percent of total billed charges,,Paid in addition to outpatient services ,123.98,,,fee schedule,,,94.5,,,percent of total billed charges,,,126.0,,,fee schedule,,,126.46,,,fee schedule,,,,,,,,,107.10,,,percent of total billed charges,,,57.96,,,percent of total billed charges,,,,,,,,,,,,,,,123.98,,,fee schedule,,,,,,,,,,,,,,,123.98,,,fee schedule,,,,,,,,,123.98,,,fee schedule,,,,,,,,
CATH BALLOON FLASH OST 7X17 X_OAB7019BA X_CORDIS C,10071426,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,2229.13,,,percent of total billed charges,,,,,,,,service not payable,1760.22,,,percent of total billed charges,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON FLASH OST 4X12 X_OAB4014BA X_CORDIS C,10071428,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,2229.13,,,percent of total billed charges,,,,,,,,service not payable,1760.22,,,percent of total billed charges,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR HF LGN SZ 7-8 9MM,10072398,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR HF LGN SZ 7-8 9MM,10072398,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUG HALF BLOCK 3 10MM X_5546-A-302 X_STRYKE,10072399,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3318.00,995.40,1287.38,2820.30,,,,,,,,,,,,,,,,,,,,1287.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1410.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2488.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1659.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2820.30,,,percent of total billed charges,,,1493.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUG HALF BLOCK 3 10MM X_5546-A-302 X_STRYKE,10072399,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3318.00,995.40,1410.15,2820.30,,,,,,,,,,,,,service not payable,,,,,,,1673.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1410.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2488.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1659.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2488.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2820.30,,,percent of total billed charges,,,1526.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH TOUR GD 6.5F 9MM,10072400,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 20.0D X_ZXROO-20.0D X_ABBOTT,10072401,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 20.0D X_ZXROO-20.0D X_ABBOTT,10072401,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR RAD NAR 8H X_54-25583 X_STRYKER,10072402,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3662.00,1098.60,1420.86,3112.70,,,,,,,,,,,,,,,,,,,,1420.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2746.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1831.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3112.70,,,percent of total billed charges,,,1647.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR RAD NAR 8H X_54-25583 X_STRYKER,10072402,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3662.00,1098.60,1556.35,3112.70,,,,,,,,,,,,,service not payable,,,,,,,1847.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1556.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2746.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1831.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2746.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3112.70,,,percent of total billed charges,,,1684.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.4X88MM X_656008 X_STRYKER,10072403,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.4X88MM X_656008 X_STRYKER,10072403,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T8 FT 2.4X20MM X_656120 X_STRYKER,10072404,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T8 FT 2.4X20MM X_656120 X_STRYKER,10072404,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR XTRA SHT LT 8 HOLE,10072409,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3283.00,984.90,1273.80,2790.55,,,,,,,,,,,,,,,,,,,,1273.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2790.55,,,percent of total billed charges,,,1477.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR XTRA SHT LT 8 HOLE,10072409,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3283.00,984.90,1395.27,2790.55,,,,,,,,,,,,,service not payable,,,,,,,1655.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2790.55,,,percent of total billed charges,,,1510.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB STR NEXGEN 15X30X75MM,10072410,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3975.00,1192.50,1542.3,3378.75,,,,,,,,,,,,,,,,,,,,1542.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1689.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2981.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1987.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3378.75,,,percent of total billed charges,,,1788.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB STR NEXGEN 15X30X75MM,10072410,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3975.00,1192.50,1689.38,3378.75,,,,,,,,,,,,,service not payable,,,,,,,2004.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1689.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2981.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1987.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2981.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3378.75,,,percent of total billed charges,,,1828.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM NEX FLT 18X130X175MM,10072411,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3806.00,1141.80,1476.73,3235.10,,,,,,,,,,,,,,,,,,,,1476.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3235.10,,,percent of total billed charges,,,1712.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM NEX FLT 18X130X175MM,10072411,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3806.00,1141.80,1617.55,3235.10,,,,,,,,,,,,,service not payable,,,,,,,1919.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3235.10,,,percent of total billed charges,,,1750.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB STEM PRECOAT SZ6,10072412,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4984.00,1495.20,1933.79,4236.40,,,,,,,,,,,,,,,,,,,,1933.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2118.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4236.40,,,percent of total billed charges,,,2242.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB STEM PRECOAT SZ6,10072412,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4984.00,1495.20,2118.20,4236.40,,,,,,,,,,,,,service not payable,,,,,,,2513.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2118.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4236.40,,,percent of total billed charges,,,2292.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LPS-FX POLYETH SZ GH5-6,10072413,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LPS-FX POLYETH SZ GH5-6,10072413,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS CANNUL 4.0MM38MM,10072640,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2566.00,769.80,995.61,2181.10,,,,,,,,,,,,,,,,,,,,995.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.10,,,percent of total billed charges,,,1154.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS CANNUL 4.0MM38MM,10072640,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2566.00,769.80,1090.55,2181.10,,,,,,,,,,,,,service not payable,,,,,,,1294.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1090.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1924.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1924.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2181.10,,,percent of total billed charges,,,1180.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING BONE RSP 5X14 X_506-03-114 X_DJ ORTH,10072641,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING BONE RSP 5X14 X_506-03-114 X_DJ ORTH,10072641,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING BONE RSP 5X18 X_506-03-118 X_DJ ORTH,10072642,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING BONE RSP 5X18 X_506-03-118 X_DJ ORTH,10072642,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SOCKET RSP HUMERAL 32X4MM STD X_508-00-432 X_DJ OR,10072643,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOCKET RSP HUMERAL 32X4MM STD X_508-00-432 X_DJ OR,10072643,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD GLENOID W/SCREW 32MM NEUT X_508-32-101 X_DJ O,10072644,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLENOID W/SCREW 32MM NEUT X_508-32-101 X_DJ O,10072644,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE RSP 30MM P2 COAT X_508-32-204 X_DJ ORTHO,10072645,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE RSP 30MM P2 COAT X_508-32-204 X_DJ ORTHO,10072645,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL STD 8X108MM X_530-08-108 X_DJ ORTHOPE,10072647,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,19507.00,5852.10,7568.72,16580.95,,9558.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8192.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7568.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8290.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14630.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9753.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16580.95,,,percent of total billed charges,,,8778.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL STD 8X108MM X_530-08-108 X_DJ ORTHOPE,10072647,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,19507.00,5852.10,8192.94,16580.95,,9558.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8192.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9839.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8290.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14630.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9753.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14630.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16580.95,,,percent of total billed charges,,,8973.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANGLE 8H X_50-780-08-09 X_KLS MARTIN L P,10072649,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2896.00,868.80,1123.65,2461.60,,,,,,,,,,,,,,,,,,,,1123.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1230.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2172.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1448.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.60,,,percent of total billed charges,,,1303.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANGLE 8H X_50-780-08-09 X_KLS MARTIN L P,10072649,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2896.00,868.80,1230.8,2461.60,,,,,,,,,,,,,service not payable,,,,,,,1460.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1230.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2172.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1448.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2172.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2461.60,,,percent of total billed charges,,,1332.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MTP STD 10D VALGUS 8D X_AR-8944C-1 X_ARTHREX,10072650,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MTP STD 10D VALGUS 8D X_AR-8944C-1 X_ARTHREX,10072650,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR HF LGN SZ 5-6 9.0MM,10072651,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR HF LGN SZ 5-6 9.0MM,10072651,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE CATH LAUNCH 6FX55CM X_LA6 IMAK X_MEDTRONIC,10072818,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,262.00,78.60,111.35,222.70,,161.92,,,percent of total billed charges,,,,,,,,service not payable,127.86,,,percent of total billed charges,,,132.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,111.35,,,percent of total billed charges,,,,,,,,,196.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,131.0,,,percent of total billed charges,,,,,,,,service not payable,196.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,222.70,,,percent of total billed charges,,,120.52,,,percent of total billed charges,,,,,,,,,170.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,170.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LIFESTREAM 135CM 10X38MM,10072820,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LIFESTREAM 135CM 10X38MM,10072820,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LIFESTREAM 135CM 6X26MM,10072821,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LIFESTREAM 135CM 6X26MM,10072821,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 12X20X75,10072822,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 44X44X100 X_VAMF4444C100TU X_,10072823,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,55713.00,16713.90,21616.64,47356.05,,27299.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23399.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,21616.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23678.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,41784.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27856.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47356.05,,,percent of total billed charges,,,25070.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 44X44X100 X_VAMF4444C100TU X_,10072823,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,55713.00,16713.90,23399.46,47356.05,,27299.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23399.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,28101.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,23678.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,41784.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,27856.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,41784.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,47356.05,,,percent of total billed charges,,,25627.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA 4.5X6.5X45MM,10072824,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA 4.5X6.5X45MM,10072824,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA 4.5X6.5X40MM,10072825,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA 4.5X6.5X40MM,10072825,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD VITALLIUM 30MM X_481322030 X_STRYKER,10072826,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD VITALLIUM 30MM X_481322030 X_STRYKER,10072826,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PLUG 4D 6X11X25MM,10072827,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PLUG 4D 6X11X25MM,10072827,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Mumps Antibody IgG,10072832,CDM,0300,RC,86735,CPT,,,,,,outpatient,facility,,,66.00,19.80,12.4,56.10,,25.70,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.79,,,fee schedule,,,19.18,,,fee schedule,,,27.22,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.01,,,fee schedule,,,12.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.05,,,fee schedule,,,29.49,,,fee schedule,,,,,,,,,12.79,,,fee schedule,,,,,,,,,16.85,,,fee schedule,,,26.62,,,fee schedule,,,49.5,,,percent of total billed charges,,,12.79,,,fee schedule,,,12.4,,,fee schedule,,,13.05,,,fee schedule,,,19.82,,,fee schedule,,,12.79,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,13.05,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,14.36,,,fee schedule,,,12.79,,,fee schedule,,,,,,,,,12.66,,,fee schedule,,,12.79,,,fee schedule,,,,,,,,,12.92,,,fee schedule,,,,,,,,
Mumps Antibody IgG,10072832,CDM,0300,RC,86735,CPT,394,EAPG,,,,outpatient,facility,,,66.00,19.80,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL FEM CANN RECON LT 11X420,10073572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5633.00,1689.90,2185.60,4788.05,,2760.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2365.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2185.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2394.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4224.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2816.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4788.05,,,percent of total billed charges,,,2534.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN RECON LT 11X420,10073572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5633.00,1689.90,2365.86,4788.05,,2760.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2365.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2841.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2394.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4224.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2816.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4224.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4788.05,,,percent of total billed charges,,,2591.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK SLFTAP T25 54X5MM,10073573,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1027.00,308.10,398.48,872.95,,,,,,,,,,,,,,,,,,,,398.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,770.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,872.95,,,percent of total billed charges,,,462.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK SLFTAP T25 54X5MM,10073573,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1027.00,308.10,436.47,872.95,,,,,,,,,,,,,service not payable,,,,,,,518.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,436.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,770.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,513.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,770.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,872.95,,,percent of total billed charges,,,472.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK SLFTAP T25 74 X 5MM,10073574,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1027.00,308.10,398.48,872.95,,,,,,,,,,,,,,,,,,,,398.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,770.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,872.95,,,percent of total billed charges,,,462.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK SLFTAP T25 74 X 5MM,10073574,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1027.00,308.10,436.47,872.95,,,,,,,,,,,,,service not payable,,,,,,,518.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,436.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,770.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,513.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,770.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,872.95,,,percent of total billed charges,,,472.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CRUCIATE SZ4,10073577,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CRUCIATE SZ4,10073577,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER GENERATOR ELUNA DR T PROMRI W/GSM HM X_4,10073581,CDM,0278,RC,C1785,HCPCS,,,,,,inpatient,facility,,,16556.00,4966.80,6423.73,14072.6,,8112.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6953.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6423.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7036.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12417.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14072.6,,,percent of total billed charges,,,7450.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER GENERATOR ELUNA DR T PROMRI W/GSM HM X_4,10073581,CDM,0278,RC,C1785,HCPCS,,,,,,outpatient,facility,,,16556.00,4966.80,6953.52,14072.6,,8112.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6953.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8350.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7036.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12417.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12417.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14072.6,,,percent of total billed charges,,,7615.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE INOGEN DF4/4 ATRIAL X_8F6A X_BOSTON SCIENTI,10073582,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,45895.00,13768.50,17807.26,39010.75,,22488.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19275.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,17807.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19505.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,34421.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22947.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39010.75,,,percent of total billed charges,,,20652.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE INOGEN DF4/4 ATRIAL X_8F6A X_BOSTON SCIENTI,10073582,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,45895.00,13768.50,19275.90,39010.75,,22488.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19275.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,23149.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,19505.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,34421.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22947.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,34421.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,39010.75,,,percent of total billed charges,,,21111.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB INOGEN DF4-DR DUAL CHMBR,10073583,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,32455.00,9736.50,12592.54,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13631.1,,,percent of total billed charges,,Paid in addition to inpatient services ,12592.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27586.75,,,percent of total billed charges,,,14604.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB INOGEN DF4-DR DUAL CHMBR,10073583,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,32455.00,9736.50,13631.1,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13631.1,,,percent of total billed charges,,Paid in addition to outpatient services ,16370.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27586.75,,,percent of total billed charges,,,14929.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALL FLASH OSTIAL 4.5X8,10073585,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,2229.13,,,percent of total billed charges,,,,,,,,service not payable,1760.22,,,percent of total billed charges,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE PRTCT EMBOLIC 320CMX3MM,10073586,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,2826.73,,,percent of total billed charges,,,,,,,,service not payable,2232.11,,,percent of total billed charges,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2287.0,,,percent of total billed charges,,,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,2973.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2973.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SEALER LIGASURE BT 5MM X 37CM,10073589,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2408.00,722.40,934.30,2046.8,,,,,,,,,,,,,,,,,,,,934.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1023.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1806.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1204.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046.8,,,percent of total billed charges,,,1083.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SEALER LIGASURE BT 5MM X 37CM,10073589,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2408.00,722.40,1023.4,2046.8,,,,,,,,,,,,,service not payable,,,,,,,1214.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1023.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1806.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1204.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1806.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2046.8,,,percent of total billed charges,,,1107.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE T 1.2MM XS 90DG NAR X_57-05140 X_STRYKER ORT,10073590,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,981.00,294.30,380.63,833.85,,,,,,,,,,,,,,,,,,,,380.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,416.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,735.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.85,,,percent of total billed charges,,,441.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE T 1.2MM XS 90DG NAR X_57-05140 X_STRYKER ORT,10073590,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,981.00,294.30,416.93,833.85,,,,,,,,,,,,,service not payable,,,,,,,494.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,735.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,490.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,735.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,833.85,,,percent of total billed charges,,,451.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR HF LGN SZ 5-6 11MM,10073591,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR HF LGN SZ 5-6 11MM,10073591,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MORCELLATOR PK OLYMPUS X_WA90200A X_OLYMPUS AMERIC,10073593,CDM,0272,RC,C1782,HCPCS,,,,,,outpatient,facility,,,15883.00,4764.90,6750.27,13500.55,,9815.69,,,percent of total billed charges,,,,,,,,service not payable,7750.90,,,percent of total billed charges,,,8011.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6750.27,,,percent of total billed charges,,,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7941.5,,,percent of total billed charges,,,,,,,,service not payable,11912.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13500.55,,,percent of total billed charges,,,7306.18,,,percent of total billed charges,,,,,,,,,10323.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,10323.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE MASTERS HP VAVGJ 21MM,10073594,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,15901.00,4770.30,6169.59,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6169.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13515.85,,,percent of total billed charges,,,7155.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE MASTERS HP VAVGJ 21MM,10073594,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,15901.00,4770.30,6678.42,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8020.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13515.85,,,percent of total billed charges,,,7314.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE INVIZIA ANT CERV 63MM,10073595,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE INVIZIA ANT CERV 63MM,10073595,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ5 12MM,10073596,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ5 12MM,10073596,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC CERVICAL KIT H5 13X15MM,10073597,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC CERVICAL KIT H5 13X15MM,10073597,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 7.5X50MM,10073900,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 7.5X50MM,10073900,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI CRVD 85 X 5.5MM,10073901,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI CRVD 85 X 5.5MM,10073901,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SPINE 3D POST LUM 12MM,10073902,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,9599.00,2879.70,3724.41,8159.15,,4703.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4031.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3724.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4079.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7199.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4799.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8159.15,,,percent of total billed charges,,,4319.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SPINE 3D POST LUM 12MM,10073902,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,9599.00,2879.70,4031.58,8159.15,,4703.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4031.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4841.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4079.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7199.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4799.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7199.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8159.15,,,percent of total billed charges,,,4415.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR ADJ 51-70 W X 6MM,10073903,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR ADJ 51-70 W X 6MM,10073903,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLYAXIAL 6.5X55MM,10073905,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLYAXIAL 6.5X55MM,10073905,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POST RADIUS 5.5X40MM,10073906,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POST RADIUS 5.5X40MM,10073906,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SPINE BIO AVS 13X25X9MM,10073907,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SPINE BIO AVS 13X25X9MM,10073907,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR CROSSLINK MED X_486614130 X_STRYKER,10073908,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR CROSSLINK MED X_486614130 X_STRYKER,10073908,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ARTHROEREISIS PROSTOP 8X14MM,10073909,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTHROEREISIS PROSTOP 8X14MM,10073909,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB VLP LFT 4H 64MM X_7282-0104 X_SMITH NEPH,10073910,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3402.00,1020.60,1319.98,2891.70,,,,,,,,,,,,,,,,,,,,1319.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2551.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1701.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2891.70,,,percent of total billed charges,,,1530.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB VLP LFT 4H 64MM X_7282-0104 X_SMITH NEPH,10073910,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3402.00,1020.60,1445.85,2891.70,,,,,,,,,,,,,service not payable,,,,,,,1715.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1445.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2551.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1701.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2551.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2891.70,,,percent of total billed charges,,,1564.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X50MM,10073911,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X50MM,10073911,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X35MM X_7110-6535S X_SMITH NEPHEW,10073912,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X35MM X_7110-6535S X_SMITH NEPHEW,10073912,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RA Exam,10075549,CDM,0320,RC,72084,CPT,,,,,,outpatient,facility,,,716.00,214.80,230.45,608.60,,442.49,,,percent of total billed charges,,,,,,,,,352.27,,,fee schedule,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,230.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RA Exam,10075549,CDM,0320,RC,72084,CPT,05522,APC,,,,outpatient,facility,,,716.00,214.80,97.82,234.20,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,214.51,,,fee schedule,,,97.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,211.41,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,97.82,,,fee schedule,,,104.01,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,97.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",104.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,102.99,,,fee schedule,,,,,,,,
RA Exam,10075549,CDM,0320,RC,72084,CPT,471,EAPG,,,,outpatient,facility,,,716.00,214.80,81.72,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,81.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,81.72,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,106.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,116.62,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10075551,CDM,0350,RC,74177,CPT,,,,,,outpatient,facility,,,5421.00,1626.30,375.0,4607.85,,443.74,,,fee schedule,,Paid in addition to outpatient services ,,,,,,,375.0,,,fee schedule,,Paid in addition to outpatient services ,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.0,,,per diem,,,,,,,,,4065.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,,4065.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4607.85,,,percent of total billed charges,,,2493.66,,,percent of total billed charges,,,,,,,,,806.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10075551,CDM,0350,RC,74177,CPT,05572,APC,,,,outpatient,facility,,,5421.00,1626.30,328.5,786.57,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,720.44,,,fee schedule,,,328.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",349.32,,,fee schedule,,,786.57,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,710.0,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,328.5,,,fee schedule,,,349.32,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,328.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",349.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,342.47,,,fee schedule,,,,,,,,,345.88,,,fee schedule,,,,,,,,
CT Exam,10075551,CDM,0350,RC,74177,CPT,300,EAPG,,,,outpatient,facility,,,5421.00,1626.30,442.27,1068.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,907.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,691.92,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,761.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10075553,CDM,0350,RC,71260,CPT,,,,,,outpatient,facility,,,2861.00,858.30,375.0,2431.85,,443.74,,,fee schedule,,Paid in addition to outpatient services ,,,,,,,375.0,,,fee schedule,,Paid in addition to outpatient services ,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.0,,,per diem,,,,,,,,,2145.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,,2145.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2431.85,,,percent of total billed charges,,,1316.06,,,percent of total billed charges,,,,,,,,,385.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10075553,CDM,0350,RC,71260,CPT,05571,APC,,,,outpatient,facility,,,2861.00,858.30,163.74,392.09,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,359.12,,,fee schedule,,,163.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",174.12,,,fee schedule,,,392.09,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,353.92,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,163.74,,,fee schedule,,,174.12,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,,,,,,,163.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",174.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,170.71,,,fee schedule,,,,,,,,,172.41,,,fee schedule,,,,,,,,
CT Exam,10075553,CDM,0350,RC,71260,CPT,300,EAPG,,,,outpatient,facility,,,2861.00,858.30,442.27,1068.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,907.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,691.92,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,761.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10076972,CDM,0350,RC,72192,CPT,,,,,,outpatient,facility,,,1776.00,532.80,230.45,1509.60,,443.74,,,fee schedule,,Paid in addition to outpatient services ,,,,,,,375.0,,,fee schedule,,Paid in addition to outpatient services ,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.0,,,per diem,,,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,230.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10076972,CDM,0350,RC,72192,CPT,05522,APC,,,,outpatient,facility,,,1776.00,532.80,97.82,234.20,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,214.51,,,fee schedule,,,97.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,211.41,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,97.82,,,fee schedule,,,104.01,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,97.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",104.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,102.99,,,fee schedule,,,,,,,,
CT Exam,10076972,CDM,0350,RC,72192,CPT,299,EAPG,,,,outpatient,facility,,,1776.00,532.80,155.26,493.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,419.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,155.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,155.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,259.78,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,285.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANN HEADLESS 3X18MM,10078099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLESS 3X18MM,10078099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY GRAFTMASTER 2.80X16MM X_1012580-16,10078100,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7861.00,2358.30,3050.07,6681.85,,3851.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3301.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3050.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3340.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5895.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3930.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6681.85,,,percent of total billed charges,,,3537.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY GRAFTMASTER 2.80X16MM X_1012580-16,10078100,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7861.00,2358.30,3301.62,6681.85,,3851.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3301.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3965.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3340.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5895.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3930.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5895.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6681.85,,,percent of total billed charges,,,3616.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY GRAFTMASTER 3.50X16MM X_1012581-16,10078101,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY GRAFTMASTER 3.50X16MM X_1012581-16,10078101,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY GRAFTMASTER 4.00X16MM X_1012582-16,10078102,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY GRAFTMASTER 4.00X16MM X_1012582-16,10078102,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE DENTAL 20 GAUGE X_01-0309 X_BIOMET,10078105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,398.00,119.40,154.42,338.30,,,,,,,,,,,,,,,,,,,,154.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,298.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.30,,,percent of total billed charges,,,179.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE DENTAL 20 GAUGE X_01-0309 X_BIOMET,10078105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,398.00,119.40,169.15,338.30,,,,,,,,,,,,,service not payable,,,,,,,200.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,169.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,298.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,199.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,298.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,338.30,,,percent of total billed charges,,,183.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CRYOPROBE 2.4 SLIMELINE X_RS-24 X_HEALTHTRONIC,10078106,CDM,0272,RC,C2618,HCPCS,,,,,,outpatient,facility,,,9173.00,2751.90,3898.53,7797.05,,5668.91,,,percent of total billed charges,,,,,,,,service not payable,4476.42,,,percent of total billed charges,,,4626.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3898.53,,,percent of total billed charges,,,,,,,,,6879.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4586.5,,,percent of total billed charges,,,,,,,,service not payable,6879.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7797.05,,,percent of total billed charges,,,4219.58,,,percent of total billed charges,,,,,,,,,5962.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5962.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD STR 5.5X100MM X_124.510 X_GLOBUS,10078107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD STR 5.5X100MM X_124.510 X_GLOBUS,10078107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON DIL AERIS 18X40,10078108,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CEMENTED SZ 6,10078109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CEMENTED SZ 6,10078109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART CONST SZ1-2 9MM X_71420959 X_SMITH NEPH,10078110,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART CONST SZ1-2 9MM X_71420959 X_SMITH NEPH,10078110,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SET TRIGEN 0MM X_71642936 X_SMITH NEPHEW,10078111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1945.00,583.50,754.66,1653.25,,,,,,,,,,,,,,,,,,,,754.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,972.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,875.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SET TRIGEN 0MM X_71642936 X_SMITH NEPHEW,10078111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1945.00,583.50,826.62,1653.25,,,,,,,,,,,,,service not payable,,,,,,,981.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,826.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,972.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN 9.0MMX34CM RT X_71640534 X_SMITH NEPHE,10078112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9639.00,2891.70,3739.93,8193.15,,4723.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4048.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3739.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4096.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8193.15,,,percent of total billed charges,,,4337.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN 9.0MMX34CM RT X_71640534 X_SMITH NEPHE,10078112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9639.00,2891.70,4048.38,8193.15,,4723.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4048.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4861.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4096.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8193.15,,,percent of total billed charges,,,4433.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCREW LAG 90/85MM X_71642690 X_SMITH NEPHEW,10078113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SCREW LAG 90/85MM X_71642690 X_SMITH NEPHEW,10078113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET HEM HA TI SOLID 58F X_500-11-58F X_STRY,10078114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET HEM HA TI SOLID 58F X_500-11-58F X_STRY,10078114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABIL BILARY 10MMX40CM,10078116,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9372.00,2811.60,3636.34,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3636.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7966.20,,,percent of total billed charges,,,4217.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABIL BILARY 10MMX40CM,10078116,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9372.00,2811.60,3936.24,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4727.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7966.20,,,percent of total billed charges,,,4311.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY TRYTON 15X3.5MM X_T5-3035-151-US X_,10078117,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3853.00,1155.90,1494.96,3275.05,,,,,,,,,,,,,,,,,,,,1494.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3275.05,,,percent of total billed charges,,,1733.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY TRYTON 15X3.5MM X_T5-3035-151-US X_,10078117,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3853.00,1155.90,1637.52,3275.05,,,,,,,,,,,,,service not payable,,,,,,,1943.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3275.05,,,percent of total billed charges,,,1772.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY TRYTON 19X3MM,10078118,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3853.00,1155.90,1494.96,3275.05,,,,,,,,,,,,,,,,,,,,1494.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3275.05,,,percent of total billed charges,,,1733.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY TRYTON 19X3MM,10078118,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3853.00,1155.90,1637.52,3275.05,,,,,,,,,,,,,service not payable,,,,,,,1943.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3275.05,,,percent of total billed charges,,,1772.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY TRYTON 19X3.5MM,10078119,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3853.00,1155.90,1494.96,3275.05,,,,,,,,,,,,,,,,,,,,1494.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3275.05,,,percent of total billed charges,,,1733.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY TRYTON 19X3.5MM,10078119,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3853.00,1155.90,1637.52,3275.05,,,,,,,,,,,,,service not payable,,,,,,,1943.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3275.05,,,percent of total billed charges,,,1772.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY TRYTON 19X2.5MM X_T5-2525-191-US X_,10078120,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3853.00,1155.90,1494.96,3275.05,,,,,,,,,,,,,,,,,,,,1494.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3275.05,,,percent of total billed charges,,,1733.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY TRYTON 19X2.5MM X_T5-2525-191-US X_,10078120,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3853.00,1155.90,1637.52,3275.05,,,,,,,,,,,,,service not payable,,,,,,,1943.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3275.05,,,percent of total billed charges,,,1772.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT CORONARY TRYTON 15X4MM X_T5-3540-151-US X_CO,10078121,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3853.00,1155.90,1494.96,3275.05,,,,,,,,,,,,,,,,,,,,1494.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3275.05,,,percent of total billed charges,,,1733.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT CORONARY TRYTON 15X4MM X_T5-3540-151-US X_CO,10078121,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3853.00,1155.90,1637.52,3275.05,,,,,,,,,,,,,service not payable,,,,,,,1943.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3275.05,,,percent of total billed charges,,,1772.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Hemogram Charge,10078125,CDM,0300,RC,85027,CPT,,,,,,outpatient,facility,,,116.00,34.80,6.15,98.60,,27.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.34,,,fee schedule,,,20.53,,,fee schedule,,,13.49,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.39,,,fee schedule,,,6.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.47,,,fee schedule,,,14.62,,,fee schedule,,,,,,,,,6.34,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.20,,,fee schedule,,,87.0,,,percent of total billed charges,,,6.34,,,fee schedule,,,6.15,,,fee schedule,,,6.47,,,fee schedule,,,9.92,,,fee schedule,,,6.34,,,fee schedule,,,87.0,,,percent of total billed charges,,,,,,,,,6.47,,,fee schedule,,,,,,,,,98.60,,,percent of total billed charges,,,53.36,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.40,,,fee schedule,,,,,,,,
Hemogram Charge,10078125,CDM,0300,RC,85027,CPT,408,EAPG,,,,outpatient,facility,,,116.00,34.80,6.99,27.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,22.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,25.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BALLOON LUTNX 4X120MM 5F X_LX351304120 X_BARD,10080322,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2299.25,4598.5,,3343.38,,,percent of total billed charges,,,,,,,,service not payable,2640.08,,,percent of total billed charges,,,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2705.0,,,percent of total billed charges,,,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,3516.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3516.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 2.5X14MM X_IH2514 X_STRYKER ORTHOPAEDIC,10080323,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 2.5X14MM X_IH2514 X_STRYKER ORTHOPAEDIC,10080323,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 3.0X14MM X_IH3014 X_STRYKER ORTHOPAEDIC,10080324,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 3.0X14MM X_IH3014 X_STRYKER ORTHOPAEDIC,10080324,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE BASE TI 6X34X24 15DEG X_6951615 X_NUVASIVE,10080325,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE BASE TI 6X34X24 15DEG X_6951615 X_NUVASIVE,10080325,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TI IMPLANT 6X38X28MM 10,10080326,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TI IMPLANT 6X38X28MM 10,10080326,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOGRAFT MAIN BODY AFX2 X_BEA25-80/113-40 X_ENDOL,10080390,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,39008.00,11702.40,15135.10,33156.80,,19113.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16383.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15135.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16578.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29256.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19504.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33156.80,,,percent of total billed charges,,,17553.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOGRAFT MAIN BODY AFX2 X_BEA25-80/113-40 X_ENDOL,10080390,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,39008.00,11702.40,16383.36,33156.80,,19113.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16383.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19675.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16578.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,29256.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19504.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29256.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,33156.80,,,percent of total billed charges,,,17943.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 22.5D TECNIS SYMFONY X_ZXT375-22.5 X_ABBOTT,10080391,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 22.5D TECNIS SYMFONY X_ZXT375-22.5 X_ABBOTT,10080391,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
AMNNION MATRIX THICK 3CMX6CM,10080392,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,12130.00,3639.00,4706.44,10310.5,,5943.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5094.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4706.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5155.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9097.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6065.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10310.5,,,percent of total billed charges,,,5458.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMNNION MATRIX THICK 3CMX6CM,10080392,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,12130.00,3639.00,5094.60,10310.5,,5943.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5094.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6118.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5155.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9097.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6065.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9097.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10310.5,,,percent of total billed charges,,,5579.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NLK HEXALOBE 3.5X8MM X_30-0255 X_ACCUMED,10080393,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1279.00,383.70,496.25,1087.15,,,,,,,,,,,,,,,,,,,,496.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,543.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,959.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1087.15,,,percent of total billed charges,,,575.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NLK HEXALOBE 3.5X8MM X_30-0255 X_ACCUMED,10080393,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1279.00,383.70,543.57,1087.15,,,,,,,,,,,,,service not payable,,,,,,,645.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,543.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,959.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,959.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1087.15,,,percent of total billed charges,,,588.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIAL PET GII RESURF OVAL 29MM X_71430429 X_SMITH,10080397,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,408.00,122.40,158.30,346.80,,,,,,,,,,,,,,,,,,,,158.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,306.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,346.80,,,percent of total billed charges,,,183.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAL PET GII RESURF OVAL 29MM X_71430429 X_SMITH,10080397,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,408.00,122.40,173.40,346.80,,,,,,,,,,,,,service not payable,,,,,,,205.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,173.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,306.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,204.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,306.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,346.80,,,percent of total billed charges,,,187.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE PLT AVIATOR ANT 14MM,10080402,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE PLT AVIATOR ANT 14MM,10080402,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Closed Tx Femoral Shaft Fracture w/Manipulation w,10080462,CDM,0450,RC,27502,CPT,,,,,,outpatient,facility,,,3210.00,963.00,774.0,2728.5,,1983.78,,,percent of total billed charges,,,,,,,,,1566.48,,,percent of total billed charges,,,1619.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2407.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2407.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2728.5,,,percent of total billed charges,,,1476.60,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Closed Tx Femoral Shaft Fracture w/Manipulation w,10080462,CDM,0450,RC,27502,CPT,05112,APC,,,,outpatient,facility,,,3210.00,963.00,736.05,3524.92,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3228.58,,,fee schedule,,,736.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1565.43,,,fee schedule,,,3524.92,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3181.79,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,736.05,,,fee schedule,,,1565.43,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,736.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1565.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,1550.03,,,fee schedule,,,,,,,,
Closed Tx Femoral Shaft Fracture w/Manipulation w,10080462,CDM,0450,RC,27502,CPT,41,EAPG,,,,outpatient,facility,,,3210.00,963.00,669.25,4928.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4928.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4189.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1856.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2042.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT TIB FB CR SZ 3 6MM X_1516-20-306 X_DEPUY,10080751,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FB CR SZ 3 6MM X_1516-20-306 X_DEPUY,10080751,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 10MM X_71453177 X_SMITH NEP,10080752,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 10MM X_71453177 X_SMITH NEP,10080752,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LISFRANC SM LFT X_AR-8951SL X_ARTHREX INC,10080838,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LISFRANC SM LFT X_AR-8951SL X_ARTHREX INC,10080838,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 15X55MM,10080839,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 15X55MM,10080839,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM COMP VERSA 46X21X50MM,10080840,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4380.00,1314.00,1699.44,3723.0,,,,,,,,,,,,,,,,,,,,1699.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3723.0,,,percent of total billed charges,,,1971.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM COMP VERSA 46X21X50MM,10080840,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4380.00,1314.00,1861.5,3723.0,,,,,,,,,,,,,service not payable,,,,,,,2209.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3723.0,,,percent of total billed charges,,,2014.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 12X14MM 5MM,10080841,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 12X14MM 5MM,10080841,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 10MMX39CM X_71655139 X_SMITH NEPHEW,10080844,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 10MMX39CM X_71655139 X_SMITH NEPHEW,10080844,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR FB SZ3 8MM X_1516-20-308 X_DEPUY,10080845,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR FB SZ3 8MM X_1516-20-308 X_DEPUY,10080845,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEMENT 3 LT X_1504-00-103 X_DEPUY,10080846,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEMENT 3 LT X_1504-00-103 X_DEPUY,10080846,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 16.0,10080847,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 16.0,10080847,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE FEED MIC GASTROSTOMY 28FR,10080848,CDM,0272,RC,B4088,HCPCS,,,,,,outpatient,facility,,,216.00,64.80,91.80,193.11,,133.49,,,percent of total billed charges,,,,,,,,service not payable,105.41,,,percent of total billed charges,,,108.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,108.0,,,fee schedule,,,193.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,108.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,91.80,,,percent of total billed charges,,,,,,,,,162.0,,,percent of total billed charges,,,,,,,,service not payable,193.11,,,fee schedule,,,,,,,,,108.0,,,percent of total billed charges,,,,,,,,service not payable,162.0,,,percent of total billed charges,,,193.11,,,fee schedule,,,97.20,,,fee schedule,,,,,,,,,183.60,,,percent of total billed charges,,,99.36,,,percent of total billed charges,,,,,,,,,140.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,140.40,,,percent of total billed charges,,,108.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
TUBE FEED MIC GASTROSTOMY 28FR,10080848,CDM,0272,RC,B4088,HCPCS,498,EAPG,,,,outpatient,facility,,,216.00,64.80,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT VIATORR 10MMX5CMX2CM 10FR X_PTB105275 X_GORE,10080849,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,14467.00,4340.10,5613.20,12296.95,,7088.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6076.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5613.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6148.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10850.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7233.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12296.95,,,percent of total billed charges,,,6510.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIATORR 10MMX5CMX2CM 10FR X_PTB105275 X_GORE,10080849,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,14467.00,4340.10,6076.14,12296.95,,7088.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6076.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7297.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6148.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10850.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7233.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10850.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12296.95,,,percent of total billed charges,,,6654.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PXT ZILVA 6X80MM 125CM X_ZISV6-35-125-80-PTX,10080850,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5885.00,1765.50,2283.38,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2283.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5002.25,,,percent of total billed charges,,,2648.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PXT ZILVA 6X80MM 125CM X_ZISV6-35-125-80-PTX,10080850,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5885.00,1765.50,2471.70,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2968.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5002.25,,,percent of total billed charges,,,2707.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEMENT 3N LT X_1504-00-123 X_DEPUY,10080984,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEMENT 3N LT X_1504-00-123 X_DEPUY,10080984,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ3 X_1504-00-223 X_DEPUY,10080985,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ3 X_1504-00-223 X_DEPUY,10080985,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ3 5MM,10080986,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ3 5MM,10080986,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FB CR SZ 3 7MM X_1516-20-307 X_DEPUY,10080987,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FB CR SZ 3 7MM X_1516-20-307 X_DEPUY,10080987,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FB CR SZ5 5MM X_1516-20-505 X_DEPUY,10080988,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FB CR SZ5 5MM X_1516-20-505 X_DEPUY,10080988,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FB CR SZ5 6MM X_1516-20-506 X_DEPUY,10080989,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FB CR SZ5 6MM X_1516-20-506 X_DEPUY,10080989,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ5 10MM,10080990,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ5 10MM,10080990,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ5 14MM X_1516-20-514 X_DEPUY,10080991,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ5 14MM X_1516-20-514 X_DEPUY,10080991,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ5 16MM X_1516-20-516 X_DEPUY,10080992,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ5 16MM X_1516-20-516 X_DEPUY,10080992,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ6 12MM X_1516-20-612 X_DEPUY,10080993,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ6 12MM X_1516-20-612 X_DEPUY,10080993,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ6 14MM,10080994,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ6 14MM,10080994,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ6 16MM X_1516-20-616 X_DEPUY,10080995,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ6 16MM X_1516-20-616 X_DEPUY,10080995,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ9 X_71316509 X_SMITH NEPHEW,10080996,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ9 X_71316509 X_SMITH NEPHEW,10080996,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ10 X_71316510 X_SMITH NEPHEW,10080997,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ10 X_71316510 X_SMITH NEPHEW,10080997,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM OXIN 12/14 28MM 8,10080998,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM OXIN 12/14 28MM 8,10080998,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 32MM 0D 16 12/14 X_71303216 X_SMITH N,10080999,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 32MM 0D 16 12/14 X_71303216 X_SMITH N,10080999,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 36MM 0D 12 12/14 X_71303612 X_SMITH N,10081000,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 36MM 0D 12 12/14 X_71303612 X_SMITH N,10081000,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 28MM ID 46MM OD X_71334946 X_SMI,10081001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 28MM ID 46MM OD X_71334946 X_SMI,10081001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 28MM ID 52MM OD 20DEG X_71334952,10081002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 28MM ID 52MM OD 20DEG X_71334952,10081002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 28MM ID 54MM OD 20DEG X_71334954,10081003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 28MM ID 54MM OD 20DEG X_71334954,10081003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 28MM ID 56MM OD 20DEG X_71334956,10081004,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 28MM ID 56MM OD 20DEG X_71334956,10081004,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 28MM ID 58MM OD 20DEG X_71334958,10081005,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 28MM ID 58MM OD 20DEG X_71334958,10081005,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 28MM ID 60MM OD 20DEG X_71334960,10081006,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 28MM ID 60MM OD 20DEG X_71334960,10081006,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 32MM ID 48MM OD 0DEG X_71339548,10081007,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 32MM ID 48MM OD 0DEG X_71339548,10081007,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 32MM ID 56MM OD 0DEG X_71339556,10081008,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 32MM ID 56MM OD 0DEG X_71339556,10081008,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 32MM ID 58MM OD 0DEG X_71339558,10081009,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 32MM ID 58MM OD 0DEG X_71339558,10081009,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 32MM ID 60MM OD 0DEG X_71339560,10081010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 32MM ID 60MM OD 0DEG X_71339560,10081010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 32MM ID 58MM OD 20DEG X_71337658,10081011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 32MM ID 58MM OD 20DEG X_71337658,10081011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 32MM ID 62MM OD 20DEG X_71337662,10081012,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 32MM ID 62MM OD 20DEG X_71337662,10081012,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 36MM ID 64MM OD 0DEG X_71332764,10081013,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 36MM ID 64MM OD 0DEG X_71332764,10081013,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 36MM ID 66-70MM OD 0DEG X_713307,10081014,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 36MM ID 66-70MM OD 0DEG X_713307,10081014,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 36MM ID 66-70MM OD 20DEG X_71331,10081015,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 36MM ID 66-70MM OD 20DEG X_71331,10081015,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 40MM ID 56MM OD 0DEG X_71338679,10081016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 40MM ID 56MM OD 0DEG X_71338679,10081016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 40MM ID 58MM OD 0DEG X_71338680,10081017,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 40MM ID 58MM OD 0DEG X_71338680,10081017,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 40MM ID 60MM OD 0DEG X_71338681,10081018,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 40MM ID 60MM OD 0DEG X_71338681,10081018,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 40MM ID 62MM OD 0DEG X_71338682,10081019,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 40MM ID 62MM OD 0DEG X_71338682,10081019,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINEAR ACETABULAR 40MM ID 64MM OD 0DEG X_71338683,10081020,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEAR ACETABULAR 40MM ID 64MM OD 0DEG X_71338683,10081020,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ9H X_71309109 X_SMITH NEPHEW,10081021,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ9H X_71309109 X_SMITH NEPHEW,10081021,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ18 X_71309018 X_SMITH NEPHEW,10081022,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ18 X_71309018 X_SMITH NEPHEW,10081022,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ10 X_71309010 X_SMITH NEPHEW,10081023,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ10 X_71309010 X_SMITH NEPHEW,10081023,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 13MM RT X_71420332 X_SMITH NEPHEW,10081024,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 13MM RT X_71420332 X_SMITH NEPHEW,10081024,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 15MM RT X_71420334 X_SMITH NEPHEW,10081025,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 15MM RT X_71420334 X_SMITH NEPHEW,10081025,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 13MM RT X_71420340 X_SMITH NEPHEW,10081026,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 13MM RT X_71420340 X_SMITH NEPHEW,10081026,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 9MM RT X_71420344 X_SMITH NEPHEW,10081027,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 9MM RT X_71420344 X_SMITH NEPHEW,10081027,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 11MM RT X_71420346 X_SMITH NEPHEW,10081028,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 11MM RT X_71420346 X_SMITH NEPHEW,10081028,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 13MM RT X_71420348 X_SMITH NEPHEW,10081029,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 13MM RT X_71420348 X_SMITH NEPHEW,10081029,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 15MM RT X_71420350 X_SMITH NEPHEW,10081030,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 15MM RT X_71420350 X_SMITH NEPHEW,10081030,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 13MM RT X_71420308 X_SMITH NEPHEW,10081031,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 13MM RT X_71420308 X_SMITH NEPHEW,10081031,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 15MM RT X_71420310 X_SMITH NEPHEW,10081032,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 15MM RT X_71420310 X_SMITH NEPHEW,10081032,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 13MM RT X_71420324 X_SMITH NEPHEW,10081033,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 13MM RT X_71420324 X_SMITH NEPHEW,10081033,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 15MM RT X_71420326 X_SMITH NEPHEW,10081034,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 15MM RT X_71420326 X_SMITH NEPHEW,10081034,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 14MM RT X_71420316 X_SMITH NEPHEW,10081035,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 14MM RT X_71420316 X_SMITH NEPHEW,10081035,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 15MM RT X_71420318 X_SMITH NEPHEW,10081036,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 15MM RT X_71420318 X_SMITH NEPHEW,10081036,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN NONRIMMED SPEED 80MM X_74013490 X_SMITH NEPHEW,10081037,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN NONRIMMED SPEED 80MM X_74013490 X_SMITH NEPHEW,10081037,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 15MM X_71420556 X_SMITH NEP,10081038,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 15MM X_71420556 X_SMITH NEP,10081038,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTIC GEN II SZ3-4 9MM X_71420523 X_SMITH N,10081039,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTIC GEN II SZ3-4 9MM X_71420523 X_SMITH N,10081039,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN RIMMED SPEED 30MM X_74013470 X_SMITH NEPHEW,10081040,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,576.00,172.80,223.49,489.60,,,,,,,,,,,,,,,,,,,,223.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,489.60,,,percent of total billed charges,,,259.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN RIMMED SPEED 30MM X_74013470 X_SMITH NEPHEW,10081040,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,576.00,172.80,244.80,489.60,,,,,,,,,,,,,service not payable,,,,,,,290.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,489.60,,,percent of total billed charges,,,264.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPIKE PROFIX BONE JOURNEY SHRT,10081041,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,576.00,172.80,223.49,489.60,,,,,,,,,,,,,,,,,,,,223.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,489.60,,,percent of total billed charges,,,259.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPIKE PROFIX BONE JOURNEY SHRT,10081041,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,576.00,172.80,244.80,489.60,,,,,,,,,,,,,service not payable,,,,,,,290.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,489.60,,,percent of total billed charges,,,264.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE SPIKE X_71512450 X_SMITH NEPHEW,10081042,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,576.00,172.80,223.49,489.60,,,,,,,,,,,,,,,,,,,,223.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,489.60,,,percent of total billed charges,,,259.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE SPIKE X_71512450 X_SMITH NEPHEW,10081042,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,576.00,172.80,244.80,489.60,,,,,,,,,,,,,service not payable,,,,,,,290.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,489.60,,,percent of total billed charges,,,264.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT PATELLAR 32MM X_71420572 X_SMITH NEPHEW,10081043,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT PATELLAR 32MM X_71420572 X_SMITH NEPHEW,10081043,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 13MM LT X_71420284 X_SMITH NEPHEW,10081044,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 13MM LT X_71420284 X_SMITH NEPHEW,10081044,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 13MM LT X_71420268 X_SMITH NEPHEW,10081045,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 13MM LT X_71420268 X_SMITH NEPHEW,10081045,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 15MM LT X_71420254 X_SMITH NEPHEW,10081046,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 15MM LT X_71420254 X_SMITH NEPHEW,10081046,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 13MM LT X_71420260 X_SMITH NEPHEW,10081047,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 13MM LT X_71420260 X_SMITH NEPHEW,10081047,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 15MM LT X_71420262 X_SMITH NEPHEW,10081048,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 15MM LT X_71420262 X_SMITH NEPHEW,10081048,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 9MM LT X_71420280 X_SMITH NEPHEW,10081049,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 9MM LT X_71420280 X_SMITH NEPHEW,10081049,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP TIB GII CR PLY SZ8 11MM LT,10081050,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP TIB GII CR PLY SZ8 11MM LT,10081050,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 13MM LT X_71420286 X_SMITH NEPHEW,10081051,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 13MM LT X_71420286 X_SMITH NEPHEW,10081051,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 13MM LT X_71420244 X_SMITH NEPHEW,10081052,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 13MM LT X_71420244 X_SMITH NEPHEW,10081052,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 15MM LT X_71420246 X_SMITH NEPHEW,10081053,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 15MM LT X_71420246 X_SMITH NEPHEW,10081053,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 15MM LT X_71420270 X_SMITH NEPHEW,10081054,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 15MM LT X_71420270 X_SMITH NEPHEW,10081054,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 15MM LT X_71420278 X_SMITH NEPHEW,10081055,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 15MM LT X_71420278 X_SMITH NEPHEW,10081055,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT LEGION FEM RT NRW SZ4,10081056,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT LEGION FEM RT NRW SZ4,10081056,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL COMPONENT LEGION SZ6 RT NAR X_71933655 X_S,10081057,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL COMPONENT LEGION SZ6 RT NAR X_71933655 X_S,10081057,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS HF LGN SZ7-8 12MM,10081058,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS HF LGN SZ7-8 12MM,10081058,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 9MM X_71420551 X_SMITH NEPH,10081059,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 9MM X_71420551 X_SMITH NEPH,10081059,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 11MM X_71420552 X_SMITH NEP,10081060,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 11MM X_71420552 X_SMITH NEP,10081060,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 13MM X_71420554 X_SMITH NEP,10081061,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 13MM X_71420554 X_SMITH NEP,10081061,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 18MM X_71420558 X_SMITH NEP,10081062,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 18MM X_71420558 X_SMITH NEP,10081062,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 21MM X_71420560 X_SMITH NEP,10081063,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 21MM X_71420560 X_SMITH NEP,10081063,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 15MM X_71453134 X_SMITH NEP,10081064,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 15MM X_71453134 X_SMITH NEP,10081064,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ7-8 12MM X_71453188 X_SMITH NEP,10081065,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ7-8 12MM X_71453188 X_SMITH NEP,10081065,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ3 RT X_71423213 X_SMITH NEPHEW,10081066,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ3 RT X_71423213 X_SMITH NEPHEW,10081066,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL LEGION X_71933644 X_SMITH NEPHEW,10081067,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL LEGION X_71933644 X_SMITH NEPHEW,10081067,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 9MM RT X_71420296 X_SMITH NEPHEW,10081068,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 9MM RT X_71420296 X_SMITH NEPHEW,10081068,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 11MM RT X_71420298 X_SMITH NEPHEW,10081069,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 11MM RT X_71420298 X_SMITH NEPHEW,10081069,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 13MM RT X_71420300 X_SMITH NEPHEW,10081070,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 13MM RT X_71420300 X_SMITH NEPHEW,10081070,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 15MM RT X_71420302 X_SMITH NEPHEW,10081071,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 15MM RT X_71420302 X_SMITH NEPHEW,10081071,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 11MM RT X_71420426 X_SMITH NEPHEW,10081072,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 11MM RT X_71420426 X_SMITH NEPHEW,10081072,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 15MM RT X_71420430 X_SMITH NEPHEW,10081073,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 15MM RT X_71420430 X_SMITH NEPHEW,10081073,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 13MM RT X_71420428 X_SMITH NEPHEW,10081074,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 13MM RT X_71420428 X_SMITH NEPHEW,10081074,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 11MM RT X_71420434 X_SMITH NEPHEW,10081075,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 11MM RT X_71420434 X_SMITH NEPHEW,10081075,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 13MM RT X_71420436 X_SMITH NEPHEW,10081076,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 13MM RT X_71420436 X_SMITH NEPHEW,10081076,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 15MM RT X_71420438 X_SMITH NEPHEW,10081077,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 15MM RT X_71420438 X_SMITH NEPHEW,10081077,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 11MM RT X_71420450 X_SMITH NEPHEW,10081078,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 11MM RT X_71420450 X_SMITH NEPHEW,10081078,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 13MM RT X_71420452 X_SMITH NEPHEW,10081079,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 13MM RT X_71420452 X_SMITH NEPHEW,10081079,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 15MM RT X_71420454 X_SMITH NEPHEW,10081080,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 15MM RT X_71420454 X_SMITH NEPHEW,10081080,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 11MM RT X_71420466 X_SMITH NEPHEW,10081081,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 11MM RT X_71420466 X_SMITH NEPHEW,10081081,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 13MM RT X_71420468 X_SMITH NEPHEW,10081082,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 13MM RT X_71420468 X_SMITH NEPHEW,10081082,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 15MM RT X_71420470 X_SMITH NEPHEW,10081083,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 15MM RT X_71420470 X_SMITH NEPHEW,10081083,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE COMPRESSION 2X30MM,10081084,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1993.00,597.90,773.28,1694.05,,,,,,,,,,,,,,,,,,,,773.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1494.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,996.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1694.05,,,percent of total billed charges,,,896.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE COMPRESSION 2X30MM,10081084,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1993.00,597.90,847.02,1694.05,,,,,,,,,,,,,service not payable,,,,,,,1005.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,847.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1494.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,996.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1494.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1694.05,,,percent of total billed charges,,,916.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3.75X32MM X_AR-7000-32 X_ARTHREX INC,10081085,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3.75X32MM X_AR-7000-32 X_ARTHREX INC,10081085,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K-WIRE 0.62X12 X_AR-8941-12 X_ARTHREX INC,10081086,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K-WIRE 0.62X12 X_AR-8941-12 X_ARTHREX INC,10081086,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3.75X34MM X_AR-7000-34 X_ARTHREX INC,10081087,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3.75X34MM X_AR-7000-34 X_ARTHREX INC,10081087,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 11MM RT X_71420474 X_SMITH NEPHEW,10081088,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 11MM RT X_71420474 X_SMITH NEPHEW,10081088,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 13MM RT X_71420476 X_SMITH NEPHEW,10081089,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 13MM RT X_71420476 X_SMITH NEPHEW,10081089,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 15MM RT X_71420478 X_SMITH NEPHEW,10081090,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 15MM RT X_71420478 X_SMITH NEPHEW,10081090,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 9MM RT X_71420456 X_SMITH NEPHEW,10081091,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 9MM RT X_71420456 X_SMITH NEPHEW,10081091,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 11MM RT X_71420458 X_SMITH NEPHEW,10081092,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 11MM RT X_71420458 X_SMITH NEPHEW,10081092,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 13MM RT X_71420460 X_SMITH NEPHEW,10081093,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 13MM RT X_71420460 X_SMITH NEPHEW,10081093,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 15MM RT X_71420462 X_SMITH NEPHEW,10081094,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 15MM RT X_71420462 X_SMITH NEPHEW,10081094,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 4MM RT X_71420440 X_SMITH NEPHEW,10081095,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 4MM RT X_71420440 X_SMITH NEPHEW,10081095,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 11MM RT X_71420442 X_SMITH NEPHEW,10081096,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 11MM RT X_71420442 X_SMITH NEPHEW,10081096,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 13MM RT X_71420444 X_SMITH NEPHEW,10081097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 13MM RT X_71420444 X_SMITH NEPHEW,10081097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 15MM RT X_71420446 X_SMITH NEPHEW,10081098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 15MM RT X_71420446 X_SMITH NEPHEW,10081098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 9MM LT X_71420408 X_SMITH NEPHEW,10081099,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 9MM LT X_71420408 X_SMITH NEPHEW,10081099,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 9MM RT X_71420472 X_SMITH NEPHEW,10081100,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 9MM RT X_71420472 X_SMITH NEPHEW,10081100,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 11M LT X_71420410 X_SMITH NEPHEW,10081101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 11M LT X_71420410 X_SMITH NEPHEW,10081101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 13MM LT X_71420412 X_SMITH NEPHEW,10081102,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 13MM LT X_71420412 X_SMITH NEPHEW,10081102,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ8 15MM LT X_71420414 X_SMITH NEPHEW,10081103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ8 15MM LT X_71420414 X_SMITH NEPHEW,10081103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 9MM LT X_71420400 X_SMITH NEPHEW,10081104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 9MM LT X_71420400 X_SMITH NEPHEW,10081104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 11MM LT X_71420402 X_SMITH NEPHEW,10081105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 11MM LT X_71420402 X_SMITH NEPHEW,10081105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 13MM LT X_71420404 X_SMITH NEPHEW,10081106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 13MM LT X_71420404 X_SMITH NEPHEW,10081106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ7 15MM LT X_71420406 X_SMITH NEPHEW,10081107,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ7 15MM LT X_71420406 X_SMITH NEPHEW,10081107,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 9MM LT X_71420392 X_SMITH NEPHEW,10081108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 9MM LT X_71420392 X_SMITH NEPHEW,10081108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 11MM LT X_71420394 X_SMITH NEPHEW,10081109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 11MM LT X_71420394 X_SMITH NEPHEW,10081109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 13MM LT X_71420396 X_SMITH NEPHEW,10081110,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 13MM LT X_71420396 X_SMITH NEPHEW,10081110,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ6 15MM LT X_71420398 X_SMITH NEPHEW,10081111,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ6 15MM LT X_71420398 X_SMITH NEPHEW,10081111,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 9MM LT X_71420384 X_SMITH NEPHEW,10081112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 9MM LT X_71420384 X_SMITH NEPHEW,10081112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 11MM LT X_71420386 X_SMITH NEPHEW,10081113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 11MM LT X_71420386 X_SMITH NEPHEW,10081113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 13MM LT X_71420388 X_SMITH NEPHEW,10081114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 13MM LT X_71420388 X_SMITH NEPHEW,10081114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ5 15MM LT X_71420390 X_SMITH NEPHEW,10081115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ5 15MM LT X_71420390 X_SMITH NEPHEW,10081115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 13MM LT X_71420380 X_SMITH NEPHEW,10081116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 13MM LT X_71420380 X_SMITH NEPHEW,10081116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ4 15MM LT X_71420382 X_SMITH NEPHEW,10081117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ4 15MM LT X_71420382 X_SMITH NEPHEW,10081117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 11MM LT X_71420370 X_SMITH NEPHEW,10081118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 11MM LT X_71420370 X_SMITH NEPHEW,10081118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 13MM LT X_71420372 X_SMITH NEPHEW,10081119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 13MM LT X_71420372 X_SMITH NEPHEW,10081119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ3 15MM LT X_71420374 X_SMITH NEPHEW,10081120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ3 15MM LT X_71420374 X_SMITH NEPHEW,10081120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 11MM LT X_71420234 X_SMITH NEPHEW,10081121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 11MM LT X_71420234 X_SMITH NEPHEW,10081121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 13MM LT X_71420236 X_SMITH NEPHEW,10081122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 13MM LT X_71420236 X_SMITH NEPHEW,10081122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL SZ2 15MM LT X_71420238 X_SMITH NEPHEW,10081123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL SZ2 15MM LT X_71420238 X_SMITH NEPHEW,10081123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ8 9MM X_5537-G-809 X_STRYKER,10081124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ8 9MM X_5537-G-809 X_STRYKER,10081124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ8 11MM X_5537-G-811 X_STRYKER,10081125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ8 11MM X_5537-G-811 X_STRYKER,10081125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ8 16MM X_5537-G-816 X_STRYKER,10081126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ8 16MM X_5537-G-816 X_STRYKER,10081126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB TRI X3 19MM SZ 8,10081127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB TRI X3 19MM SZ 8,10081127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON CATH PTA 4X120 4F X_U8130412 X_BARD,10081922,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1012.00,303.60,430.10,860.20,,625.42,,,percent of total billed charges,,,,,,,,service not payable,493.86,,,percent of total billed charges,,,510.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,430.10,,,percent of total billed charges,,,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,506.0,,,percent of total billed charges,,,,,,,,service not payable,759.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,860.20,,,percent of total billed charges,,,465.52,,,percent of total billed charges,,,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,657.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IMPACT 5MMX120MMX130CM,10081923,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5607.00,1682.10,2382.97,4765.95,,3465.13,,,percent of total billed charges,,,,,,,,service not payable,2736.22,,,percent of total billed charges,,,2828.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2382.97,,,percent of total billed charges,,,,,,,,,4205.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,4205.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4765.95,,,percent of total billed charges,,,2579.22,,,percent of total billed charges,,,,,,,,,3644.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3644.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SUPERA 5X100 X_S-50-100-120-P6 X_ABBOTT VASC,10081924,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4770.00,1431.00,1850.76,4054.5,,,,,,,,,,,,,,,,,,,,1850.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4054.5,,,percent of total billed charges,,,2146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SUPERA 5X100 X_S-50-100-120-P6 X_ABBOTT VASC,10081924,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4770.00,1431.00,2027.25,4054.5,,,,,,,,,,,,,service not payable,,,,,,,2405.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4054.5,,,percent of total billed charges,,,2194.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CRS SZ 8,10081925,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CRS SZ 8,10081925,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K-WIRE BONE 3.2X450MM,10082419,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,595.00,178.50,230.86,505.75,,,,,,,,,,,,,,,,,,,,230.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.75,,,percent of total billed charges,,,267.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K-WIRE BONE 3.2X450MM,10082419,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,595.00,178.50,252.88,505.75,,,,,,,,,,,,,service not payable,,,,,,,300.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,252.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,446.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,446.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,505.75,,,percent of total billed charges,,,273.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE INTEGRA 1000CC,10082420,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5738.00,1721.40,2226.34,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2226.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4877.30,,,percent of total billed charges,,,2582.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE INTEGRA 1000CC,10082420,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2409.96,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2X19MM X_25-872-19-91 X_KLS MARTIN L P,10082421,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,226.00,67.80,87.69,192.10,,,,,,,,,,,,,,,,,,,,87.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.10,,,percent of total billed charges,,,101.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2X19MM X_25-872-19-91 X_KLS MARTIN L P,10082421,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,226.00,67.80,96.05,192.10,,,,,,,,,,,,,service not payable,,,,,,,113.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,169.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.10,,,percent of total billed charges,,,103.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE ATTUNE PAT RESECT SHIM,10082423,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1077.00,323.10,417.88,915.45,,,,,,,,,,,,,,,,,,,,417.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,807.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,538.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915.45,,,percent of total billed charges,,,484.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE ATTUNE PAT RESECT SHIM,10082423,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1077.00,323.10,457.72,915.45,,,,,,,,,,,,,service not payable,,,,,,,543.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,457.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,807.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,538.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,807.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,915.45,,,percent of total billed charges,,,495.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 3X3CM X_GS-5330 X_MIMEDX,10082424,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 3X3CM X_GS-5330 X_MIMEDX,10082424,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM C-TPR 40MM 7.5 X_06-4075 X_STRYKER ORTHOP,10084096,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM C-TPR 40MM 7.5 X_06-4075 X_STRYKER ORTHOP,10084096,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CMNT LNG RT 7 X_6088-0730-250R X_STRYKER ORTH,10084097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17056.00,5116.80,6617.73,14497.6,,8357.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7163.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6617.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7248.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12792.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8528.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14497.6,,,percent of total billed charges,,,7675.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CMNT LNG RT 7 X_6088-0730-250R X_STRYKER ORTH,10084097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17056.00,5116.80,7163.52,14497.6,,8357.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7163.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8603.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7248.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12792.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8528.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12792.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14497.6,,,percent of total billed charges,,,7845.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR NANTCK 1.4MM 1.2MM X_CAT02969 X_STRYKER END,10084098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2697.00,809.10,1046.44,2292.45,,,,,,,,,,,,,,,,,,,,1046.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2022.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,,1213.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR NANTCK 1.4MM 1.2MM X_CAT02969 X_STRYKER END,10084098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2697.00,809.10,1146.22,2292.45,,,,,,,,,,,,,service not payable,,,,,,,1360.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1146.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2022.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2022.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,,1240.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARI 13MM X_8780213 X_NUVASIVE,10084099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARI 13MM X_8780213 X_NUVASIVE,10084099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FRAG-LOC X_30-0372 X_FUSION MEDICAL,10084100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,612.00,183.60,237.46,520.20,,,,,,,,,,,,,,,,,,,,237.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,459.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.20,,,percent of total billed charges,,,275.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FRAG-LOC X_30-0372 X_FUSION MEDICAL,10084100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,612.00,183.60,260.10,520.20,,,,,,,,,,,,,service not payable,,,,,,,308.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,260.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,459.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,459.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,520.20,,,percent of total billed charges,,,281.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ANTERIOR TIBIALLIS 18-23,10084102,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4458.00,1337.40,1729.70,3789.30,,,,,,,,,,,,,,,,,,,,1729.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1894.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3789.30,,,percent of total billed charges,,,2006.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ANTERIOR TIBIALLIS 18-23,10084102,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4458.00,1337.40,1894.65,3789.30,,,,,,,,,,,,,service not payable,,,,,,,2248.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1894.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3343.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3789.30,,,percent of total billed charges,,,2050.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MTP REVISION LFT X_7282-4017S X_SMITH NEPHEW,10084103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3966.00,1189.80,1538.81,3371.10,,,,,,,,,,,,,,,,,,,,1538.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1685.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2974.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1983.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3371.10,,,percent of total billed charges,,,1784.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MTP REVISION LFT X_7282-4017S X_SMITH NEPHEW,10084103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3966.00,1189.80,1685.55,3371.10,,,,,,,,,,,,,service not payable,,,,,,,2000.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1685.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2974.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1983.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2974.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3371.10,,,percent of total billed charges,,,1824.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX LK ST 2.7X20MM X_7282-3120 X_SMITH NE,10084105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,627.00,188.10,243.28,532.95,,,,,,,,,,,,,,,,,,,,243.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.95,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX LK ST 2.7X20MM X_7282-3120 X_SMITH NE,10084105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,627.00,188.10,266.47,532.95,,,,,,,,,,,,,service not payable,,,,,,,316.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,532.95,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FT OSTEOPENIA 4.0X40MM X_7282-3240 X_SMITH N,10084106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,317.00,95.10,123.00,269.45,,,,,,,,,,,,,,,,,,,,123.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,237.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.45,,,percent of total billed charges,,,142.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT OSTEOPENIA 4.0X40MM X_7282-3240 X_SMITH N,10084106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,317.00,95.10,134.72,269.45,,,,,,,,,,,,,service not payable,,,,,,,159.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,134.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,237.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,158.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,237.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,269.45,,,percent of total billed charges,,,145.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK OSTEOPENIA 4.0X14MM X_7282-3414 X_SMITH N,10084107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,927.00,278.10,359.68,787.95,,,,,,,,,,,,,,,,,,,,359.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,393.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,695.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,463.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.95,,,percent of total billed charges,,,417.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK OSTEOPENIA 4.0X14MM X_7282-3414 X_SMITH N,10084107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,927.00,278.10,393.97,787.95,,,,,,,,,,,,,service not payable,,,,,,,467.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,393.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,695.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,463.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,695.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,787.95,,,percent of total billed charges,,,426.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK OSTEOPENIA 4.0X20MM X_7282-3420 X_SMITH N,10084108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,927.00,278.10,359.68,787.95,,,,,,,,,,,,,,,,,,,,359.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,393.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,695.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,463.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.95,,,percent of total billed charges,,,417.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK OSTEOPENIA 4.0X20MM X_7282-3420 X_SMITH N,10084108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,927.00,278.10,393.97,787.95,,,,,,,,,,,,,service not payable,,,,,,,467.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,393.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,695.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,463.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,695.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,787.95,,,percent of total billed charges,,,426.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LIFE 6F 20MM X_EX070203CS X_BARD,10084109,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LIFE 6F 20MM X_EX070203CS X_BARD,10084109,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 10X26X120,10084110,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 10X26X120,10084110,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP V40 TMZF 28MM -4,10084111,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP V40 TMZF 28MM -4,10084111,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 28MM -2.5 X_18-28-3 X_STRYKER,10084112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 28MM -2.5 X_18-28-3 X_STRYKER,10084112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 28MM 0 X_18-2800 X_STRYKER,10084113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 28MM 0 X_18-2800 X_STRYKER,10084113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 28MM 2.5 X_18-2825 X_STRYKER,10084114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 28MM 2.5 X_18-2825 X_STRYKER,10084114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM C TAPER 28MM 5.0MM,10084115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM C TAPER 28MM 5.0MM,10084115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM EXETER SZ 4 50MM,10084116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM EXETER SZ 4 50MM,10084116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32F X_STRYKER,10084117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5156.00,1546.80,2000.53,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2000.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4382.60,,,percent of total billed charges,,,2320.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32F X_STRYKER,10084117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5156.00,1546.80,2165.52,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2600.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4382.60,,,percent of total billed charges,,,2371.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32G X_STRYKER,10084118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5156.00,1546.80,2000.53,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2000.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4382.60,,,percent of total billed charges,,,2320.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32G X_STRYKER,10084118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5156.00,1546.80,2165.52,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2600.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4382.60,,,percent of total billed charges,,,2371.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32H X_STRYKER,10084119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5156.00,1546.80,2000.53,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2000.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4382.60,,,percent of total billed charges,,,2320.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32H X_STRYKER,10084119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5156.00,1546.80,2165.52,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2600.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4382.60,,,percent of total billed charges,,,2371.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32I X_STRYKER,10084120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5156.00,1546.80,2000.53,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2000.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4382.60,,,percent of total billed charges,,,2320.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ECCENTRIC 32MM 10DEG X_663-10-32I X_STRYKER,10084120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5156.00,1546.80,2165.52,4382.60,,2526.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2165.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2600.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2191.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3867.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3867.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4382.60,,,percent of total billed charges,,,2371.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ECCENTRIC 36MM 10DEG X_663-10-36H X_STRYKER,10084121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5507.00,1652.10,2136.72,4680.95,,2698.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2312.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2136.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2340.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2753.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4680.95,,,percent of total billed charges,,,2478.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ECCENTRIC 36MM 10DEG X_663-10-36H X_STRYKER,10084121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5507.00,1652.10,2312.94,4680.95,,2698.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2312.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2777.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2340.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4130.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2753.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4680.95,,,percent of total billed charges,,,2533.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ECCENTRIC 36MM 10DEG X_663-10-36I X_STRYKER,10084122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5507.00,1652.10,2136.72,4680.95,,2698.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2312.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2136.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2340.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2753.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4680.95,,,percent of total billed charges,,,2478.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ECCENTRIC 36MM 10DEG X_663-10-36I X_STRYKER,10084122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5507.00,1652.10,2312.94,4680.95,,2698.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2312.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2777.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2340.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4130.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2753.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4680.95,,,percent of total billed charges,,,2533.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD C-TAPER STD 28MM 5 X_06-2805 X_STRYKER,10084123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD C-TAPER STD 28MM 5 X_06-2805 X_STRYKER,10084123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD C-TAPER STD 28MM 10 X_06-2810 X_STRYKER,10084124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD C-TAPER STD 28MM 10 X_06-2810 X_STRYKER,10084124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD C-TAPER X_S-1400-HH84 X_STRYKER,10084125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD C-TAPER X_S-1400-HH84 X_STRYKER,10084125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIDENT 32MM X3 X_623-10-32I X_STRYKER,10084126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIDENT 32MM X3 X_623-10-32I X_STRYKER,10084126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIDENT 32MM X3 X_623-10-32H X_STRYKER,10084127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIDENT 32MM X3 X_623-10-32H X_STRYKER,10084127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP SZ4 X_6051-0425S X_STRYKER,10084128,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP SZ4 X_6051-0425S X_STRYKER,10084128,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP SZ5 X_6051-0525S X_STRYKER,10084129,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP SZ5 X_6051-0525S X_STRYKER,10084129,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP SZ6 X_6051-0625S X_STRYKER,10084130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP SZ6 X_6051-0625S X_STRYKER,10084130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD C-TAPER 36MM 10 X_06-3610 X_STRYKER,10084131,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD C-TAPER 36MM 10 X_06-3610 X_STRYKER,10084131,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ANG NECK SZ0 27MM 127DEG X_6721-0027 X_ST,10084133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ANG NECK SZ0 27MM 127DEG X_6721-0027 X_ST,10084133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ANG NECK SZ1 27MM 127DEG X_6721-0127 X_ST,10084134,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ANG NECK SZ1 27MM 127DEG X_6721-0127 X_ST,10084134,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM V40 127D SZ 9,10084135,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM V40 127D SZ 9,10084135,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ANG NECK SZ10 40MM 127DEG X_6721-1040 X_S,10084136,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ANG NECK SZ10 40MM 127DEG X_6721-1040 X_S,10084136,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ANG NECK SZ11 40MM 127DEG X_6721-1140 X_S,10084137,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ANG NECK SZ11 40MM 127DEG X_6721-1140 X_S,10084137,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ACCOLADE II SZ0 132DEG X_6720-0027 X_STRY,10084138,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ACCOLADE II SZ0 132DEG X_6720-0027 X_STRY,10084138,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ACCOLADE II SZ1 132DEG X_6720-0127 X_STRY,10084139,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ACCOLADE II SZ1 132DEG X_6720-0127 X_STRY,10084139,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ACCOLADE II SZ9 132DEG X_6720-0937 X_STRY,10084140,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ACCOLADE II SZ9 132DEG X_6720-0937 X_STRY,10084140,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ACCOLADE II SZ11 132DEG X_6720-1140 X_STR,10084141,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ACCOLADE II SZ11 132DEG X_6720-1140 X_STR,10084141,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIDENT 32MM X_623-00-32H X_STRYKER,10084142,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIDENT 32MM X_623-00-32H X_STRYKER,10084142,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIDENT 32MM X3 X_623-00-32I X_STRYKER,10084143,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIDENT 32MM X3 X_623-00-32I X_STRYKER,10084143,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL HEMISPHERICAL CL 66MM X_502-03-66H X_STRYKER,10084144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL HEMISPHERICAL CL 66MM X_502-03-66H X_STRYKER,10084144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB 6.0 MULTIPC 15.5,10084146,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,733.00,219.90,284.40,623.05,,,,,,,,,,,,,,,,,,,,284.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,549.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,366.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.05,,,percent of total billed charges,,,329.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB 6.0 MULTIPC 15.5,10084146,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,733.00,219.90,311.52,623.05,,,,,,,,,,,,,service not payable,,,,,,,369.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,311.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,549.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,366.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,549.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,623.05,,,percent of total billed charges,,,337.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 19.5 X_MTA3U0-19.5 X_ALCON LAB INC,10086107,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 19.5 X_MTA3U0-19.5 X_ALCON LAB INC,10086107,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM LFT 40MM X_6260-9-432 X_STRYKER,10086108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM LFT 40MM X_6260-9-432 X_STRYKER,10086108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM STD SZ 20 135D 190MM,10086109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM STD SZ 20 135D 190MM,10086109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANCELLOUS 6.5X60MM,10086110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANCELLOUS 6.5X60MM,10086110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANCELLOUS 6.5X50MM,10086111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANCELLOUS 6.5X50MM,10086111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET NEUT 36X62MM 4,10086112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4962.00,1488.60,1925.26,4217.70,,,,,,,,,,,,,,,,,,,,1925.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4217.70,,,percent of total billed charges,,,2232.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET NEUT 36X62MM 4,10086112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4962.00,1488.60,2108.85,4217.70,,,,,,,,,,,,,service not payable,,,,,,,2502.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4217.70,,,percent of total billed charges,,,2282.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET NEUT 36X66MM 4,10086113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4962.00,1488.60,1925.26,4217.70,,,,,,,,,,,,,,,,,,,,1925.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4217.70,,,percent of total billed charges,,,2232.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET NEUT 36X66MM 4,10086113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4962.00,1488.60,2108.85,4217.70,,,,,,,,,,,,,service not payable,,,,,,,2502.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4217.70,,,percent of total billed charges,,,2282.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL 9H X_71306109 X_SMITH NEPHEW,10086114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL 9H X_71306109 X_SMITH NEPHEW,10086114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET 10D 36X64MM 4,10086115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4962.00,1488.60,1925.26,4217.70,,,,,,,,,,,,,,,,,,,,1925.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4217.70,,,percent of total billed charges,,,2232.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET 10D 36X64MM 4,10086115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4962.00,1488.60,2108.85,4217.70,,,,,,,,,,,,,service not payable,,,,,,,2502.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4217.70,,,percent of total billed charges,,,2282.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET 10D 36X62MM 4,10086116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4962.00,1488.60,1925.26,4217.70,,,,,,,,,,,,,,,,,,,,1925.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4217.70,,,percent of total billed charges,,,2232.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET 10D 36X62MM 4,10086116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4962.00,1488.60,2108.85,4217.70,,,,,,,,,,,,,service not payable,,,,,,,2502.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4217.70,,,percent of total billed charges,,,2282.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET FEM 10D 36X52MM 4,10086117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4962.00,1488.60,1925.26,4217.70,,,,,,,,,,,,,,,,,,,,1925.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4217.70,,,percent of total billed charges,,,2232.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET FEM 10D 36X52MM 4,10086117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4962.00,1488.60,2108.85,4217.70,,,,,,,,,,,,,service not payable,,,,,,,2502.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2108.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3721.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2481.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3721.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4217.70,,,percent of total billed charges,,,2282.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ9 X_71306609 X_SMITH NEPHEW,10086119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ9 X_71306609 X_SMITH NEPHEW,10086119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIAL KNEE PFC SZ 5 15MM,10086120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4710.00,1413.00,1827.48,4003.5,,,,,,,,,,,,,,,,,,,,1827.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3532.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2355.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4003.5,,,percent of total billed charges,,,2119.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIAL KNEE PFC SZ 5 15MM,10086120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4710.00,1413.00,2001.75,4003.5,,,,,,,,,,,,,service not payable,,,,,,,2375.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2001.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3532.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2355.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3532.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4003.5,,,percent of total billed charges,,,2166.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KNEE SZ 2 15MM,10086121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4710.00,1413.00,1827.48,4003.5,,,,,,,,,,,,,,,,,,,,1827.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3532.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2355.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4003.5,,,percent of total billed charges,,,2119.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KNEE SZ 2 15MM,10086121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4710.00,1413.00,2001.75,4003.5,,,,,,,,,,,,,service not payable,,,,,,,2375.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2001.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3532.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2355.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3532.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4003.5,,,percent of total billed charges,,,2166.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ1 9MM X_5531-G-109 X_STRYK,10086122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ1 9MM X_5531-G-109 X_STRYK,10086122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ2 19MM X_5531-G-219 X_STRY,10086123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ2 19MM X_5531-G-219 X_STRY,10086123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ2 16MM X_5531-G-216 X_STRY,10086124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ2 16MM X_5531-G-216 X_STRY,10086124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ3 19MM X_5531-G-319 X_STRY,10086125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ3 19MM X_5531-G-319 X_STRY,10086125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ4 19MM X_5531-G-419 X_STRY,10086126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ4 19MM X_5531-G-419 X_STRY,10086126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ6 19MM X_5531-G-619 X_STRY,10086127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ6 19MM X_5531-G-619 X_STRY,10086127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ6 16MM X_5531-G-616 X_STRY,10086128,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ6 16MM X_5531-G-616 X_STRY,10086128,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ7 19MM X_5531-G-719 X_STRY,10086129,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ7 19MM X_5531-G-719 X_STRY,10086129,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ7 16MM X_5531-G-716 X_STRY,10086130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ7 16MM X_5531-G-716 X_STRY,10086130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB KNEE TRI SZ 8 11MM,10086131,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB KNEE TRI SZ 8 11MM,10086131,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ2 9MM X_5537-G-209 X_STRYK,10086132,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ2 9MM X_5537-G-209 X_STRYK,10086132,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ2 11MM X_5537-G-211 X_STRY,10086133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ2 11MM X_5537-G-211 X_STRY,10086133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC/BILIARY 8X60X135,10086134,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC/BILIARY 8X60X135,10086134,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LUMINEXX 10X20 X_ZBM10020 X_BARD,10086135,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LUMINEXX 10X20 X_ZBM10020 X_BARD,10086135,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LUMINEXX 10X10 X_ZBL10100 X_BARD,10086136,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LUMINEXX 10X10 X_ZBL10100 X_BARD,10086136,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 7X56MM 120CM 6F,10086137,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 7X56MM 120CM 6F,10086137,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPAVER STEM FEM DISTAL 17MM,10086138,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPAVER STEM FEM DISTAL 17MM,10086138,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TEM OMNI EON 127DEG X_6097-0425 X_STRYKER,10086139,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TEM OMNI EON 127DEG X_6097-0425 X_STRYKER,10086139,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
UNITRAX MODULAR ENDO HEAD 61MM X_6942-5-061 X_STRY,10086140,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UNITRAX MODULAR ENDO HEAD 61MM X_6942-5-061 X_STRY,10086140,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB KNEE TRI SZ 8 13MM,10086141,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB KNEE TRI SZ 8 13MM,10086141,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ8 19MM X_5531-G-819 X_STRY,10086142,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ8 19MM X_5531-G-819 X_STRY,10086142,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW PK 7X20MM X_72202262 X_SMITH NEPHEW,10086143,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1409.00,422.70,546.69,1197.65,,,,,,,,,,,,,,,,,,,,546.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1056.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,704.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1197.65,,,percent of total billed charges,,,634.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW PK 7X20MM X_72202262 X_SMITH NEPHEW,10086143,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1409.00,422.70,598.82,1197.65,,,,,,,,,,,,,service not payable,,,,,,,710.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,598.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1056.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,704.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1056.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1197.65,,,percent of total billed charges,,,648.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW PK 8X20MM X_72202266 X_SMITH NEPHEW,10086144,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1342.00,402.60,520.70,1140.7,,,,,,,,,,,,,,,,,,,,520.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.7,,,percent of total billed charges,,,603.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW PK 8X20MM X_72202266 X_SMITH NEPHEW,10086144,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1342.00,402.60,570.35,1140.7,,,,,,,,,,,,,service not payable,,,,,,,676.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,617.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE BIOSURE 8X30MM,10086145,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1342.00,402.60,520.70,1140.7,,,,,,,,,,,,,,,,,,,,520.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.7,,,percent of total billed charges,,,603.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE BIOSURE 8X30MM,10086145,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1342.00,402.60,570.35,1140.7,,,,,,,,,,,,,service not payable,,,,,,,676.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,617.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW PK 9X20MM X_72202271 X_SMITH NEPHEW,10086146,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1342.00,402.60,520.70,1140.7,,,,,,,,,,,,,,,,,,,,520.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.7,,,percent of total billed charges,,,603.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW PK 9X20MM X_72202271 X_SMITH NEPHEW,10086146,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1342.00,402.60,570.35,1140.7,,,,,,,,,,,,,service not payable,,,,,,,676.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,617.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW PK 10X30MM X_72202277 X_SMITH NEPHEW,10086147,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1342.00,402.60,520.70,1140.7,,,,,,,,,,,,,,,,,,,,520.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.7,,,percent of total billed charges,,,603.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW PK 10X30MM X_72202277 X_SMITH NEPHEW,10086147,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1342.00,402.60,570.35,1140.7,,,,,,,,,,,,,service not payable,,,,,,,676.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,570.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1006.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,671.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1006.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,617.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW HA 8X30MM X_72201778 X_SMITH NEPHEW,10086148,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1392.00,417.60,540.10,1183.2,,,,,,,,,,,,,,,,,,,,540.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,,626.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW HA 8X30MM X_72201778 X_SMITH NEPHEW,10086148,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1392.00,417.60,591.60,1183.2,,,,,,,,,,,,,service not payable,,,,,,,702.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,,640.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW HA 9X35MM X_72201783 X_SMITH NEPHEW,10086149,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1392.00,417.60,540.10,1183.2,,,,,,,,,,,,,,,,,,,,540.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,,626.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW HA 9X35MM X_72201783 X_SMITH NEPHEW,10086149,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1392.00,417.60,591.60,1183.2,,,,,,,,,,,,,service not payable,,,,,,,702.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,,640.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW HA 11X30MM X_72201789 X_SMITH NEPHEW,10086150,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1392.00,417.60,540.10,1183.2,,,,,,,,,,,,,,,,,,,,540.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,,626.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW HA 11X30MM X_72201789 X_SMITH NEPHEW,10086150,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1392.00,417.60,591.60,1183.2,,,,,,,,,,,,,service not payable,,,,,,,702.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,,640.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIOSURE SCREW HA 8X20MM X_72201775 X_SMITH NEPHEW,10086151,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1392.00,417.60,540.10,1183.2,,,,,,,,,,,,,,,,,,,,540.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,,626.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIOSURE SCREW HA 8X20MM X_72201775 X_SMITH NEPHEW,10086151,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1392.00,417.60,591.60,1183.2,,,,,,,,,,,,,service not payable,,,,,,,702.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,591.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1044.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1044.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,,640.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOBUTTON CL ULTRA 35MM X_72200150 X_SMITH NEPHEW,10086152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1523.00,456.90,590.92,1294.55,,,,,,,,,,,,,,,,,,,,590.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1294.55,,,percent of total billed charges,,,685.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOBUTTON CL ULTRA 35MM X_72200150 X_SMITH NEPHEW,10086152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1523.00,456.90,647.27,1294.55,,,,,,,,,,,,,service not payable,,,,,,,768.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1294.55,,,percent of total billed charges,,,700.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOBUTTON CL ULTRA 40MM X_72200151 X_SMITH NEPHEW,10086153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1523.00,456.90,590.92,1294.55,,,,,,,,,,,,,,,,,,,,590.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1294.55,,,percent of total billed charges,,,685.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOBUTTON CL ULTRA 40MM X_72200151 X_SMITH NEPHEW,10086153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1523.00,456.90,647.27,1294.55,,,,,,,,,,,,,service not payable,,,,,,,768.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1294.55,,,percent of total billed charges,,,700.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOBUTTON CL ULTRA 45MM X_72200152 X_SMITH NEPHEW,10086154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1523.00,456.90,590.92,1294.55,,,,,,,,,,,,,,,,,,,,590.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1294.55,,,percent of total billed charges,,,685.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOBUTTON CL ULTRA 45MM X_72200152 X_SMITH NEPHEW,10086154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1523.00,456.90,647.27,1294.55,,,,,,,,,,,,,service not payable,,,,,,,768.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1294.55,,,percent of total billed charges,,,700.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOBUTTON CL ULTRA 50MM X_72200153 X_SMITH NEPHEW,10086155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1523.00,456.90,590.92,1294.55,,,,,,,,,,,,,,,,,,,,590.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1294.55,,,percent of total billed charges,,,685.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOBUTTON CL ULTRA 50MM X_72200153 X_SMITH NEPHEW,10086155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1523.00,456.90,647.27,1294.55,,,,,,,,,,,,,service not payable,,,,,,,768.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,647.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1142.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,761.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1142.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1294.55,,,percent of total billed charges,,,700.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CMPRS INTERRAN 30MM X_71672030 X_SMITH NEPHE,10086156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1047.00,314.10,406.24,889.95,,,,,,,,,,,,,,,,,,,,406.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,785.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,523.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,889.95,,,percent of total billed charges,,,471.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CMPRS INTERRAN 30MM X_71672030 X_SMITH NEPHE,10086156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1047.00,314.10,444.97,889.95,,,,,,,,,,,,,service not payable,,,,,,,528.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,444.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,785.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,523.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,785.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,889.95,,,percent of total billed charges,,,481.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 11X70MM X_71678070 X_SMITH NEPHEW,10086157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2141.00,642.30,830.71,1819.85,,,,,,,,,,,,,,,,,,,,830.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1605.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1070.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1819.85,,,percent of total billed charges,,,963.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 11X70MM X_71678070 X_SMITH NEPHEW,10086157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2141.00,642.30,909.92,1819.85,,,,,,,,,,,,,service not payable,,,,,,,1079.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,909.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1605.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1070.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1605.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1819.85,,,percent of total billed charges,,,984.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX18CM 125D,10086158,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3634.00,1090.20,1409.99,3088.90,,,,,,,,,,,,,,,,,,,,1409.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1817.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3088.90,,,percent of total billed charges,,,1635.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX18CM 125D,10086158,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3634.00,1090.20,1544.45,3088.90,,,,,,,,,,,,,service not payable,,,,,,,1832.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1544.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2725.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1817.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2725.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3088.90,,,percent of total billed charges,,,1671.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX18CM 130DEG X_71675384 X_SMITH NEPHEW,10086159,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3634.00,1090.20,1409.99,3088.90,,,,,,,,,,,,,,,,,,,,1409.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1817.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3088.90,,,percent of total billed charges,,,1635.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX18CM 130DEG X_71675384 X_SMITH NEPHEW,10086159,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3634.00,1090.20,1544.45,3088.90,,,,,,,,,,,,,service not payable,,,,,,,1832.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1544.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2725.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1817.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2725.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3088.90,,,percent of total billed charges,,,1671.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX18CM 130DEG X_71675208 X_SMITH NEPHEW,10086160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3742.00,1122.60,1451.90,3180.70,,,,,,,,,,,,,,,,,,,,1451.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1590.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2806.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3180.70,,,percent of total billed charges,,,1683.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX18CM 130DEG X_71675208 X_SMITH NEPHEW,10086160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3742.00,1122.60,1590.35,3180.70,,,,,,,,,,,,,service not payable,,,,,,,1887.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2806.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1871.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2806.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3180.70,,,percent of total billed charges,,,1721.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX32CM 125DEG LT X_71675407 X_SMITH NEPHEW,10086161,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX32CM 125DEG LT X_71675407 X_SMITH NEPHEW,10086161,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX34CM 125DEG LT X_71675409 X_SMITH NEPHEW,10086162,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX34CM 125DEG LT X_71675409 X_SMITH NEPHEW,10086162,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX36CM 125DEG LT X_71675411 X_SMITH NEPHEW,10086163,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX36CM 125DEG LT X_71675411 X_SMITH NEPHEW,10086163,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX38CM 125DEG LT X_71676601 X_SMITH NEPHEW,10086164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX38CM 125DEG LT X_71676601 X_SMITH NEPHEW,10086164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX42CM 125DEG LT X_71675417 X_SMITH NEPHEW,10086165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX42CM 125DEG LT X_71675417 X_SMITH NEPHEW,10086165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX34CM 125DEG LT X_71676553 X_SMITH NEPH,10086166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX34CM 125DEG LT X_71676553 X_SMITH NEPH,10086166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EVERA XT MRI DR X_DRMMEM X_MEDTRONIC USA INC,10086189,CDM,0278,RC,C1721,HCPCS,,,,,,inpatient,facility,,,51010.00,15303.00,19791.88,43358.5,,24994.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21424.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,19791.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21679.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38257.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25505.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43358.5,,,percent of total billed charges,,,22954.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EVERA XT MRI DR X_DRMMEM X_MEDTRONIC USA INC,10086189,CDM,0278,RC,C1721,HCPCS,,,,,,outpatient,facility,,,51010.00,15303.00,21424.20,43358.5,,24994.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21424.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,25729.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21679.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38257.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25505.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38257.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43358.5,,,percent of total billed charges,,,23464.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR BROKEN SCRW 2MM CANN,10086190,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR BROKEN SCRW 3MM CANN,10086191,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR BROKEN SCRW 4MM CANN,10086192,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR BROKEN SCRW 5MM CANN,10086193,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR STRPD SCRW 2MM CANN,10086196,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR STRPD SCRW 3MM CANN,10086197,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR STRPD SCRW 4MM CANN,10086199,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR STRPD SCRW 6MM CANN,10086201,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTRACTOR STRPD SCRW 7MM CANN,10086202,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,945.54,,,percent of total billed charges,,,,,,,,service not payable,746.64,,,percent of total billed charges,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,994.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SZ F3N RT 59X55.6MM X_NX027Z X_AESCULAP,10086209,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SZ F3N RT 59X55.6MM X_NX027Z X_AESCULAP,10086209,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDING SURFACE PS T1/T1 12MM,10086210,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDING SURFACE PS T1/T1 12MM,10086210,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CEM SZ F3N LFT 59X55.6MM X_NX007Z X_AESCU,10086211,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CEM SZ F3N LFT 59X55.6MM X_NX007Z X_AESCU,10086211,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 12X14MM 7MM,10086212,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 12X14MM 7MM,10086212,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR PEEK S-TAK KNOTLESS 3X12.77MM X_AR-1938PS X,10086213,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR PEEK S-TAK KNOTLESS 3X12.77MM X_AR-1938PS X,10086213,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM COMP VERSA 46X24X47MM,10086214,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4380.00,1314.00,1699.44,3723.0,,,,,,,,,,,,,,,,,,,,1699.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3723.0,,,percent of total billed charges,,,1971.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM COMP VERSA 46X24X47MM,10086214,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4380.00,1314.00,1861.5,3723.0,,,,,,,,,,,,,service not payable,,,,,,,2209.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3723.0,,,percent of total billed charges,,,2014.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X46MM X_7382-2346 X_SMITH NEPHEW,10086215,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,494.00,148.20,191.67,419.90,,,,,,,,,,,,,,,,,,,,191.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,370.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,247.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.90,,,percent of total billed charges,,,222.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X46MM X_7382-2346 X_SMITH NEPHEW,10086215,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,494.00,148.20,209.95,419.90,,,,,,,,,,,,,service not payable,,,,,,,249.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,370.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,247.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,370.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.90,,,percent of total billed charges,,,227.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 9X50MM REVERE X_124.096 X_GLOBUS,10086216,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 9X50MM REVERE X_124.096 X_GLOBUS,10086216,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5X60MM REVERE POLYAXIL X_124.777 X_GLOBUS,10086217,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5X60MM REVERE POLYAXIL X_124.777 X_GLOBUS,10086217,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT SCLERAL BUCKLING 6MM,10086218,CDM,0278,RC,C1784,HCPCS,,,,,,inpatient,facility,,,145.00,43.50,56.26,123.25,,,,,,,,,,,,,,,,,,,,56.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,108.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT SCLERAL BUCKLING 6MM,10086218,CDM,0278,RC,C1784,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.62,123.25,,,,,,,,,,,,,service not payable,,,,,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDING CONVEY MODEL 6FR,10086219,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,317.00,95.10,134.72,269.45,,195.91,,,percent of total billed charges,,,,,,,,service not payable,154.70,,,percent of total billed charges,,,159.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,134.72,,,percent of total billed charges,,,,,,,,,237.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,158.5,,,percent of total billed charges,,,,,,,,service not payable,237.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,269.45,,,percent of total billed charges,,,145.82,,,percent of total billed charges,,,,,,,,,206.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,206.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX32CM 130DEG LT X_71675429 X_SMITH NEPHEW,10086233,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX32CM 130DEG LT X_71675429 X_SMITH NEPHEW,10086233,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX34CM 130DEG LT X_71675431 X_SMITH NEPHEW,10086234,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX34CM 130DEG LT X_71675431 X_SMITH NEPHEW,10086234,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX36CM 130DEG LT X_71675433 X_SMITH NEPHEW,10086235,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX36CM 130DEG LT X_71675433 X_SMITH NEPHEW,10086235,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX42CM 130DEG LT X_71675439 X_SMITH NEPHEW,10086236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX42CM 130DEG LT X_71675439 X_SMITH NEPHEW,10086236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCREW LAG 120/115 X_71677120 X_SMITH NEPHEW,10086237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2665.00,799.50,1034.02,2265.25,,,,,,,,,,,,,,,,,,,,1034.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2265.25,,,percent of total billed charges,,,1199.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SCREW LAG 120/115 X_71677120 X_SMITH NEPHEW,10086237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2665.00,799.50,1132.62,2265.25,,,,,,,,,,,,,service not payable,,,,,,,1344.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2265.25,,,percent of total billed charges,,,1225.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCREW LAG 70/65 X_71677070 X_SMITH NEPHEW,10086238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2665.00,799.50,1034.02,2265.25,,,,,,,,,,,,,,,,,,,,1034.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2265.25,,,percent of total billed charges,,,1199.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SCREW LAG 70/65 X_71677070 X_SMITH NEPHEW,10086238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2665.00,799.50,1132.62,2265.25,,,,,,,,,,,,,service not payable,,,,,,,1344.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2265.25,,,percent of total billed charges,,,1225.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCREW LAG 75/70 X_71677075 X_SMITH NEPHEW,10086239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2665.00,799.50,1034.02,2265.25,,,,,,,,,,,,,,,,,,,,1034.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2265.25,,,percent of total billed charges,,,1199.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SCREW LAG 75/70 X_71677075 X_SMITH NEPHEW,10086239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2665.00,799.50,1132.62,2265.25,,,,,,,,,,,,,service not payable,,,,,,,1344.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2265.25,,,percent of total billed charges,,,1225.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX32CM 130DEG RT X_71675430 X_SMITH NEPHEW,10086240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX32CM 130DEG RT X_71675430 X_SMITH NEPHEW,10086240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX34CM 130DEG RT X_71675432 X_SMITH NEPHEW,10086241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX34CM 130DEG RT X_71675432 X_SMITH NEPHEW,10086241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX40CM 130DEG RT X_71675438 X_SMITH NEPHEW,10086242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX40CM 130DEG RT X_71675438 X_SMITH NEPHEW,10086242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX42CM 130DEG RT X_71675440 X_SMITH NEPHEW,10086243,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX42CM 130DEG RT X_71675440 X_SMITH NEPHEW,10086243,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX32CM 130DEG RT X_71676574 X_SMITH NEPH,10086244,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX32CM 130DEG RT X_71676574 X_SMITH NEPH,10086244,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX38CM 130D R,10086245,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX38CM 130D R,10086245,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX40CM 130DEG RT X_71676582 X_SMITH NEPH,10086246,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX40CM 130DEG RT X_71676582 X_SMITH NEPH,10086246,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX42CM 130DEG RT X_71676584 X_SMITH NEPH,10086247,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX42CM 130DEG RT X_71676584 X_SMITH NEPH,10086247,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX42CM 130DEG RT X_71675540 X_SMITH NEPHEW,10086248,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX42CM 130DEG RT X_71675540 X_SMITH NEPHEW,10086248,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX32CM 125DEG RT X_71675408 X_SMITH NEPHEW,10086249,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX32CM 125DEG RT X_71675408 X_SMITH NEPHEW,10086249,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX34CM 125DEG RT X_71675410 X_SMITH NEPHEW,10086250,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX34CM 125DEG RT X_71675410 X_SMITH NEPHEW,10086250,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX36CM 125DEG RT X_71675412 X_SMITH NEPHEW,10086251,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX36CM 125DEG RT X_71675412 X_SMITH NEPHEW,10086251,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX42CM 125DEG RT X_71675418 X_SMITH NEPHEW,10086252,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX42CM 125DEG RT X_71675418 X_SMITH NEPHEW,10086252,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX42CM 125D R,10086253,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX42CM 125D R,10086253,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX44CM 125DEG RT X_71676564 X_SMITH NEPH,10086254,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX44CM 125DEG RT X_71676564 X_SMITH NEPH,10086254,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX30CM 125DEG RT X_71675527 X_SMITH NEPHEW,10086255,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX30CM 125DEG RT X_71675527 X_SMITH NEPHEW,10086255,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5X10MM X_71645110 X_SMITH NEPHEW,10086256,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5X10MM X_71645110 X_SMITH NEPHEW,10086256,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5X100MM X_71645100 X_SMITH NEPHEW,10086257,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5X100MM X_71645100 X_SMITH NEPHEW,10086257,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5X105MM X_71645105 X_SMITH NEPHEW,10086258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5X105MM X_71645105 X_SMITH NEPHEW,10086258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5X72.5MM X_71645072 X_SMITH NEPHEW,10086260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5X72.5MM X_71645072 X_SMITH NEPHEW,10086260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5X20MM X_71645020 X_SMITH NEPHEW,10086261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5X20MM X_71645020 X_SMITH NEPHEW,10086261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TRIGEN 4.5X57.5MM X_71645457 X_SMITH NEPH,10086262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TRIGEN 4.5X57.5MM X_71645457 X_SMITH NEPH,10086262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TRIGEN 4.5X22.5MM X_71645422 X_SMITH NEPH,10086263,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TRIGEN 4.5X22.5MM X_71645422 X_SMITH NEPH,10086263,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP NAIL 15MM X_71634015 X_SMITH NEPHEW,10086264,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,798.00,239.40,309.62,678.30,,,,,,,,,,,,,,,,,,,,309.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,399.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.30,,,percent of total billed charges,,,359.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP NAIL 15MM X_71634015 X_SMITH NEPHEW,10086264,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,798.00,239.40,339.15,678.30,,,,,,,,,,,,,service not payable,,,,,,,402.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,339.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,598.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,399.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,598.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,678.30,,,percent of total billed charges,,,367.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP NAIL 5MM X_71634005 X_SMITH NEPHEW,10086265,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,798.00,239.40,309.62,678.30,,,,,,,,,,,,,,,,,,,,309.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,399.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.30,,,percent of total billed charges,,,359.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP NAIL 5MM X_71634005 X_SMITH NEPHEW,10086265,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,798.00,239.40,339.15,678.30,,,,,,,,,,,,,service not payable,,,,,,,402.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,339.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,598.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,399.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,598.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,678.30,,,percent of total billed charges,,,367.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP NAIL 10MM X_71634010 X_SMITH NEPHEW,10086266,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,798.00,239.40,309.62,678.30,,,,,,,,,,,,,,,,,,,,309.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,399.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.30,,,percent of total billed charges,,,359.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP NAIL 10MM X_71634010 X_SMITH NEPHEW,10086266,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,798.00,239.40,339.15,678.30,,,,,,,,,,,,,service not payable,,,,,,,402.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,339.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,598.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,399.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,598.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,678.30,,,percent of total billed charges,,,367.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TRIGEN 4.5X62.5MM X_71645462 X_SMITH NEPH,10086267,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,856.00,256.80,332.13,727.60,,,,,,,,,,,,,,,,,,,,332.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.60,,,percent of total billed charges,,,385.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TRIGEN 4.5X62.5MM X_71645462 X_SMITH NEPH,10086267,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,856.00,256.80,363.80,727.60,,,,,,,,,,,,,service not payable,,,,,,,431.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,363.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,642.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,727.60,,,percent of total billed charges,,,393.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX32CM 130DEG LT X_71676573 X_SMITH NEPH,10086268,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX32CM 130DEG LT X_71676573 X_SMITH NEPH,10086268,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X60MM,10086269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,502.00,150.60,194.78,426.70,,,,,,,,,,,,,,,,,,,,194.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.70,,,percent of total billed charges,,,225.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X60MM,10086269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,502.00,150.60,213.35,426.70,,,,,,,,,,,,,service not payable,,,,,,,253.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,376.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,426.70,,,percent of total billed charges,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X90MM X_73805090 X_SMITH NEPHEW,10086270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X90MM X_73805090 X_SMITH NEPHEW,10086270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X44MM X_73805044 X_SMITH NEPHEW,10086271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,502.00,150.60,194.78,426.70,,,,,,,,,,,,,,,,,,,,194.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.70,,,percent of total billed charges,,,225.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X44MM X_73805044 X_SMITH NEPHEW,10086271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,502.00,150.60,213.35,426.70,,,,,,,,,,,,,service not payable,,,,,,,253.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,376.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,426.70,,,percent of total billed charges,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X46MM X_73805046 X_SMITH NEPHEW,10086272,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,502.00,150.60,194.78,426.70,,,,,,,,,,,,,,,,,,,,194.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.70,,,percent of total billed charges,,,225.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X46MM X_73805046 X_SMITH NEPHEW,10086272,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,502.00,150.60,213.35,426.70,,,,,,,,,,,,,service not payable,,,,,,,253.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,376.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,426.70,,,percent of total billed charges,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X48MM X_73805048 X_SMITH NEPHEW,10086273,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,502.00,150.60,194.78,426.70,,,,,,,,,,,,,,,,,,,,194.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.70,,,percent of total billed charges,,,225.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X48MM X_73805048 X_SMITH NEPHEW,10086273,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,502.00,150.60,213.35,426.70,,,,,,,,,,,,,service not payable,,,,,,,253.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,376.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,426.70,,,percent of total billed charges,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X50MM X_73805050 X_SMITH NEPHEW,10086274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,502.00,150.60,194.78,426.70,,,,,,,,,,,,,,,,,,,,194.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.70,,,percent of total billed charges,,,225.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X50MM X_73805050 X_SMITH NEPHEW,10086274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,502.00,150.60,213.35,426.70,,,,,,,,,,,,,service not payable,,,,,,,253.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,376.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,426.70,,,percent of total billed charges,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL T20 3.5X55MM X_73805055 X_SMITH NEPHEW,10086275,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,502.00,150.60,194.78,426.70,,,,,,,,,,,,,,,,,,,,194.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.70,,,percent of total billed charges,,,225.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL T20 3.5X55MM X_73805055 X_SMITH NEPHEW,10086275,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,502.00,150.60,213.35,426.70,,,,,,,,,,,,,service not payable,,,,,,,253.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,376.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,426.70,,,percent of total billed charges,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX PL T20 3.5X90MM X_73804090 X_SMITH NEPH,10086276,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,141.00,42.30,54.71,119.85,,,,,,,,,,,,,,,,,,,,54.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,105.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.85,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX PL T20 3.5X90MM X_73804090 X_SMITH NEPH,10086276,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,141.00,42.30,59.92,119.85,,,,,,,,,,,,,service not payable,,,,,,,71.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,105.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,70.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,105.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,119.85,,,percent of total billed charges,,,64.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX PL T20 3.5X95MM X_73804095 X_SMITH NEPH,10086277,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,141.00,42.30,54.71,119.85,,,,,,,,,,,,,,,,,,,,54.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,105.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.85,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX PL T20 3.5X95MM X_73804095 X_SMITH NEPH,10086277,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,141.00,42.30,59.92,119.85,,,,,,,,,,,,,service not payable,,,,,,,71.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,105.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,70.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,105.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,119.85,,,percent of total billed charges,,,64.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 8.5MMX28CM X_71655028 X_SMITH NEPHEW,10086280,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 8.5MMX28CM X_71655028 X_SMITH NEPHEW,10086280,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 8.5MMX26CM X_71655026 X_SMITH NEPHEW,10086281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 8.5MMX26CM X_71655026 X_SMITH NEPHEW,10086281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 8.5MMX24CM X_71655024 X_SMITH NEPHEW,10086282,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 8.5MMX24CM X_71655024 X_SMITH NEPHEW,10086282,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 8.5MMX40CM X_71655040 X_SMITH NEPHEW,10086283,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 8.5MMX40CM X_71655040 X_SMITH NEPHEW,10086283,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 10MMX28CM X_71655128 X_SMITH NEPHEW,10086284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 10MMX28CM X_71655128 X_SMITH NEPHEW,10086284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 10MMX37CM X_71655137 X_SMITH NEPHEW,10086285,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 10MMX37CM X_71655137 X_SMITH NEPHEW,10086285,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 10MMX35CM X_71655135 X_SMITH NEPHEW,10086286,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 10MMX35CM X_71655135 X_SMITH NEPHEW,10086286,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX35CM X_71655235 X_SMITH NEPHEW,10086287,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX35CM X_71655235 X_SMITH NEPHEW,10086287,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX34CM X_71655234 X_SMITH NEPHEW,10086288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX34CM X_71655234 X_SMITH NEPHEW,10086288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX33CM X_71655233 X_SMITH NEPHEW,10086289,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX33CM X_71655233 X_SMITH NEPHEW,10086289,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX32CM X_71655232 X_SMITH NEPHEW,10086290,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX32CM X_71655232 X_SMITH NEPHEW,10086290,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX30CM X_71655230 X_SMITH NEPHEW,10086291,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX30CM X_71655230 X_SMITH NEPHEW,10086291,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX40CM X_71655240 X_SMITH NEPHEW,10086292,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX40CM X_71655240 X_SMITH NEPHEW,10086292,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX39CM X_71655239 X_SMITH NEPHEW,10086293,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX39CM X_71655239 X_SMITH NEPHEW,10086293,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX38CM X_71655238 X_SMITH NEPHEW,10086294,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX38CM X_71655238 X_SMITH NEPHEW,10086294,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 11.5MMX37CM X_71655237 X_SMITH NEPHEW,10086295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4436.00,1330.80,1721.17,3770.60,,,,,,,,,,,,,,,,,,,,1721.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3770.60,,,percent of total billed charges,,,1996.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 11.5MMX37CM X_71655237 X_SMITH NEPHEW,10086295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4436.00,1330.80,1885.3,3770.60,,,,,,,,,,,,,service not payable,,,,,,,2237.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1885.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3770.60,,,percent of total billed charges,,,2040.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AMBI CHSP 5SL 120MM 130DEG X_121135 X_SMITH,10086296,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2009.00,602.70,779.49,1707.65,,,,,,,,,,,,,,,,,,,,779.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.65,,,percent of total billed charges,,,904.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AMBI CHSP 5SL 120MM 130DEG X_121135 X_SMITH,10086296,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2009.00,602.70,853.82,1707.65,,,,,,,,,,,,,service not payable,,,,,,,1013.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1707.65,,,percent of total billed charges,,,924.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AMBI CHSP 4SL 100MM 140DEG X_121132 X_SMITH,10086297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2009.00,602.70,779.49,1707.65,,,,,,,,,,,,,,,,,,,,779.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.65,,,percent of total billed charges,,,904.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AMBI CHSP 4SL 100MM 140DEG X_121132 X_SMITH,10086297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2009.00,602.70,853.82,1707.65,,,,,,,,,,,,,service not payable,,,,,,,1013.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1707.65,,,percent of total billed charges,,,924.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AMBI CHSP 3SL 80MM 140D,10086298,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2009.00,602.70,779.49,1707.65,,,,,,,,,,,,,,,,,,,,779.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.65,,,percent of total billed charges,,,904.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AMBI CHSP 3SL 80MM 140D,10086298,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2009.00,602.70,853.82,1707.65,,,,,,,,,,,,,service not payable,,,,,,,1013.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1707.65,,,percent of total billed charges,,,924.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AMBI CHSP 3SL 60MM 140DEG X_121122 X_SMITH N,10086299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1824.00,547.20,707.71,1550.40,,,,,,,,,,,,,,,,,,,,707.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,775.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1368.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,912.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1550.40,,,percent of total billed charges,,,820.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AMBI CHSP 3SL 60MM 140DEG X_121122 X_SMITH N,10086299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1824.00,547.20,775.20,1550.40,,,,,,,,,,,,,service not payable,,,,,,,920.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,775.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1368.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,912.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1368.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1550.40,,,percent of total billed charges,,,839.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 5MM X_1516-40-205 X_DEPUY,10086300,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 5MM X_1516-40-205 X_DEPUY,10086300,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 8MM X_1516-40-208 X_DEPUY,10086301,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 8MM X_1516-40-208 X_DEPUY,10086301,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 10MM X_1516-40-210 X_DEPUY,10086302,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 10MM X_1516-40-210 X_DEPUY,10086302,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ2 10MM X_1516-50-210 X_DEPUY,10086303,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ2 10MM X_1516-50-210 X_DEPUY,10086303,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ2 8MM X_1516-50-208 X_DEPUY,10086304,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ2 8MM X_1516-50-208 X_DEPUY,10086304,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS CEM SZ2 RT,10086305,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS CEM SZ2 RT,10086305,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 12MM X_1516-40-212 X_DEPUY,10086306,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 12MM X_1516-40-212 X_DEPUY,10086306,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 14MM X_1516-40-214 X_DEPUY,10086307,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 14MM X_1516-40-214 X_DEPUY,10086307,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 16MM X_1516-40-216 X_DEPUY,10086308,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 16MM X_1516-40-216 X_DEPUY,10086308,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 18MM X_1516-40-218 X_DEPUY,10086309,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 18MM X_1516-40-218 X_DEPUY,10086309,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ2 12MM X_1516-50-212 X_DEPUY,10086310,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ2 12MM X_1516-50-212 X_DEPUY,10086310,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ2 14MM X_1516-50-214 X_DEPUY,10086311,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ2 14MM X_1516-50-214 X_DEPUY,10086311,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ2 16MM X_1516-50-216 X_DEPUY,10086312,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ2 16MM X_1516-50-216 X_DEPUY,10086312,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ2 18MM X_1516-50-218 X_DEPUY,10086313,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ2 18MM X_1516-50-218 X_DEPUY,10086313,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS CEM SZ10 RT X_1504-10-210 X_DEPUY,10086314,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS CEM SZ10 RT X_1504-10-210 X_DEPUY,10086314,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS CEM SZ10 LT X_1504-10-110 X_DEPUY,10086315,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS CEM SZ10 LT X_1504-10-110 X_DEPUY,10086315,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 5MM X_1516-41-005 X_DEPUY,10086316,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 5MM X_1516-41-005 X_DEPUY,10086316,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 6MM X_1516-41-006 X_DEPUY,10086317,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 6MM X_1516-41-006 X_DEPUY,10086317,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 7MM X_1516-41-007 X_DEPUY,10086318,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 7MM X_1516-41-007 X_DEPUY,10086318,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 8MM X_1516-41-008 X_DEPUY,10086319,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 8MM X_1516-41-008 X_DEPUY,10086319,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 10MM X_1516-41-010 X_DEPUY,10086320,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 10MM X_1516-41-010 X_DEPUY,10086320,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 12MM X_1516-41-012 X_DEPUY,10086321,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 12MM X_1516-41-012 X_DEPUY,10086321,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 14MM X_1516-41-014 X_DEPUY,10086322,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 14MM X_1516-41-014 X_DEPUY,10086322,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 16MM X_1516-41-016 X_DEPUY,10086323,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 16MM X_1516-41-016 X_DEPUY,10086323,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 18MM X_1516-41-018 X_DEPUY,10086324,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 18MM X_1516-41-018 X_DEPUY,10086324,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ10 120MM X_1516-41-020 X_DEPUY,10086325,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ10 120MM X_1516-41-020 X_DEPUY,10086325,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 7MM X_1516-40-907 X_DEPUY,10086326,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 7MM X_1516-40-907 X_DEPUY,10086326,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 10MM X_1516-40-910 X_DEPUY,10086327,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 10MM X_1516-40-910 X_DEPUY,10086327,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 12MM X_1516-40-912 X_DEPUY,10086328,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 12MM X_1516-40-912 X_DEPUY,10086328,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 14MM X_1516-40-914 X_DEPUY,10086329,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 14MM X_1516-40-914 X_DEPUY,10086329,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 16MM X_1516-40-916 X_DEPUY,10086330,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 16MM X_1516-40-916 X_DEPUY,10086330,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 18MM X_1516-40-918 X_DEPUY,10086331,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 18MM X_1516-40-918 X_DEPUY,10086331,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ9 20MM X_1516-40-920 X_DEPUY,10086332,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ9 20MM X_1516-40-920 X_DEPUY,10086332,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM VLIFT 18X32MM X_48291832 X_STRYKER ORTHOPAE,10088713,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM VLIFT 18X32MM X_48291832 X_STRYKER ORTHOPAE,10088713,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP END 18MM 0DEG X_48291180 X_STRYKER ORTHOPAEDIC,10088714,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2102.00,630.60,815.58,1786.7,,,,,,,,,,,,,,,,,,,,815.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1576.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1051.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1786.7,,,percent of total billed charges,,,945.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP END 18MM 0DEG X_48291180 X_STRYKER ORTHOPAEDIC,10088714,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2102.00,630.60,893.35,1786.7,,,,,,,,,,,,,service not payable,,,,,,,1060.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,893.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1576.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1051.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1576.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1786.7,,,percent of total billed charges,,,966.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 4.5 5.5X40 X_48145540 X_STRYKER ORTHOPAE,10088715,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 4.5 5.5X40 X_48145540 X_STRYKER ORTHOPAE,10088715,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 4.5 5.5X35 X_48145535 X_STRYKER ORTHOPAE,10088716,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 4.5 5.5X35 X_48145535 X_STRYKER ORTHOPAE,10088716,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 4.5X480MM X_48133200 X_STRYKER ORTHOPAEDIC,10088717,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 4.5X480MM X_48133200 X_STRYKER ORTHOPAEDIC,10088717,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DUAL HOLE CAUDAL SM X_48130110 X_STRYKER OR,10088718,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4104.00,1231.20,1592.35,3488.40,,,,,,,,,,,,,,,,,,,,1592.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1744.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3078.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3488.40,,,percent of total billed charges,,,1846.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DUAL HOLE CAUDAL SM X_48130110 X_STRYKER OR,10088718,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4104.00,1231.20,1744.2,3488.40,,,,,,,,,,,,,service not payable,,,,,,,2070.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1744.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3078.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3078.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3488.40,,,percent of total billed charges,,,1887.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DUAL HOLE ROSTRAL SM X_48130111 X_STRYKER O,10088719,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4104.00,1231.20,1592.35,3488.40,,,,,,,,,,,,,,,,,,,,1592.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1744.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3078.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3488.40,,,percent of total billed charges,,,1846.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DUAL HOLE ROSTRAL SM X_48130111 X_STRYKER O,10088719,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4104.00,1231.20,1744.2,3488.40,,,,,,,,,,,,,service not payable,,,,,,,2070.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1744.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3078.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3078.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3488.40,,,percent of total billed charges,,,1887.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP FEMUR NARROW F4NR X_NN909Z X_AESCULAP,10088720,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP FEMUR NARROW F4NR X_NN909Z X_AESCULAP,10088720,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE KNEE PFC RT SZ 3.0 16MM,10088721,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE KNEE PFC RT SZ 3.0 16MM,10088721,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB KNEE TC3 SZ2.5 25MM,10088722,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7461.00,2238.30,2894.87,6341.85,,3655.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3133.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2894.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3170.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5595.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3730.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6341.85,,,percent of total billed charges,,,3357.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB KNEE TC3 SZ2.5 25MM,10088722,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7461.00,2238.30,3133.62,6341.85,,3655.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3133.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3763.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3170.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5595.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3730.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5595.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6341.85,,,percent of total billed charges,,,3432.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL RM/LL SZ4 8MM X_5630-G-428 X_STRYKER,10088723,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL RM/LL SZ4 8MM X_5630-G-428 X_STRYKER,10088723,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL 40X17MM X_5552-S-4017 X_STRYKER ORTHO,10088724,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3667.00,1100.10,1422.80,3116.95,,,,,,,,,,,,,,,,,,,,1422.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3116.95,,,percent of total billed charges,,,1650.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL 40X17MM X_5552-S-4017 X_STRYKER ORTHO,10088724,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3667.00,1100.10,1558.47,3116.95,,,,,,,,,,,,,service not payable,,,,,,,1849.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3116.95,,,percent of total billed charges,,,1686.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VANSCHIES 1 5FR 65CM,10088725,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KN SIGMA 6X20MM,10090096,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KN SIGMA 6X20MM,10090096,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KNEE 5X20MM,10090097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KNEE 5X20MM,10090097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KNEE FXD 2X20MM,10090098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KNEE FXD 2X20MM,10090098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ 1.5 8X58X38MM,10090099,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ 1.5 8X58X38MM,10090099,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SZ 1.5 12.5X58X38MM,10090100,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SZ 1.5 12.5X58X38MM,10090100,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SZ 1.5 15.0X58X38MM,10090101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SZ 1.5 15.0X58X38MM,10090101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SZ 6.0 15.0X89X59MM,10090102,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SZ 6.0 15.0X89X59MM,10090102,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SZ 6.0 17.5X89X59MM,10090103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SZ 6.0 17.5X89X59MM,10090103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 28 12-14 15.5MM,10090104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 28 12-14 15.5MM,10090104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALTRX PINNACLE 10D 36X66 4MM,10090105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTRX PINNACLE 10D 36X66 4MM,10090105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ7 130D 133X41MM,10090106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ7 130D 133X41MM,10090106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL HIP ACETABULAR 44MM,10090107,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL HIP ACETABULAR 44MM,10090107,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM PINN 10D 28X44 4MM,10090108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM PINN 10D 28X44 4MM,10090108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM PINN 10D 28X46 4MM,10090109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM PINN 10D 28X46 4MM,10090109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACCETABULAR HIP 28X44MM,10090110,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACCETABULAR HIP 28X44MM,10090110,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SIGMA TC3 LT SZ 2.0,10090111,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20906.00,6271.80,8111.53,17770.10,,10243.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8780.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8111.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8885.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15679.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10453.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17770.10,,,percent of total billed charges,,,9407.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SIGMA TC3 LT SZ 2.0,10090111,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20906.00,6271.80,8780.52,17770.10,,10243.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8780.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10544.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8885.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15679.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10453.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15679.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17770.10,,,percent of total billed charges,,,9616.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB PFC CRUC SZ 2.5 15MM,10090112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB PFC CRUC SZ 2.5 15MM,10090112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Tracheostoma revision simple without flap rotatio,10090132,CDM,0450,RC,31613,CPT,,,,,,outpatient,facility,,,5736.00,1720.80,774.0,4875.60,,3544.85,,,percent of total billed charges,,,,,,,,,2799.17,,,percent of total billed charges,,,2893.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4302.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4302.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4875.60,,,percent of total billed charges,,,2638.56,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tracheostoma revision simple without flap rotatio,10090132,CDM,0450,RC,31613,CPT,05164,APC,,,,outpatient,facility,,,5736.00,1720.80,1491.53,7142.89,,,,,,,,3110.0,,,fee schedule,,,,,,,,,,,,,,,6542.38,,,fee schedule,,,1491.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3172.20,,,fee schedule,,,7142.89,,,fee schedule,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,,,,,,,6447.56,,,fee schedule,,,,,,,,,3110.0,,,fee schedule,,,1491.53,,,fee schedule,,,3172.20,,,fee schedule,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,1491.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3172.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,,,,,,,3110.0,,,fee schedule,,,,,,,,,3140.98,,,fee schedule,,,,,,,,
Tracheostoma revision simple without flap rotatio,10090132,CDM,0450,RC,31613,CPT,72,EAPG,,,,outpatient,facility,,,5736.00,1720.80,2990.92,6194.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6194.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5265.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2990.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2990.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2990.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4271.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4698.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL FEM ACETABULAR 58MM,10090175,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR 58MM,10090175,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 0D 40X58MM,10090176,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 0D 40X58MM,10090176,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CEM SZ5,10090177,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14716.00,4414.80,5709.81,12508.6,,7210.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6180.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5709.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6254.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11037.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12508.6,,,percent of total billed charges,,,6622.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CEM SZ5,10090177,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14716.00,4414.80,6180.72,12508.6,,7210.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6180.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7422.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6254.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11037.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11037.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12508.6,,,percent of total billed charges,,,6769.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DUOFX TPR SMMT SZ10 130D,10090178,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DUOFX TPR SMMT SZ10 130D,10090178,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CROSS DRIVE 1.8X5MM X_25-976-05-1 X_KLS,10090181,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,221.00,66.30,85.75,187.85,,,,,,,,,,,,,,,,,,,,85.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,165.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,110.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.85,,,percent of total billed charges,,,99.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CROSS DRIVE 1.8X5MM X_25-976-05-1 X_KLS,10090181,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,221.00,66.30,93.92,187.85,,,,,,,,,,,,,service not payable,,,,,,,111.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,165.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,110.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,165.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,187.85,,,percent of total billed charges,,,101.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREWDRIVER 1.5X58X2.0MM X_25-433-97-07 X_KLS MART,10090182,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,876.00,262.80,339.89,744.60,,,,,,,,,,,,,,,,,,,,339.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,657.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.60,,,percent of total billed charges,,,394.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREWDRIVER 1.5X58X2.0MM X_25-433-97-07 X_KLS MART,10090182,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,876.00,262.80,372.30,744.60,,,,,,,,,,,,,service not payable,,,,,,,441.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,372.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,657.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,438.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,657.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,744.60,,,percent of total billed charges,,,402.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS NAR SZ3 LT X_1504-10-123 X_DEPUY,10090187,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS NAR SZ3 LT X_1504-10-123 X_DEPUY,10090187,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ3 10MM X_1516-40-312 X_DEPUY,10090188,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ3 10MM X_1516-40-312 X_DEPUY,10090188,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ3 12MM X_1516-40-314 X_DEPUY,10090189,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ3 12MM X_1516-40-314 X_DEPUY,10090189,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ3 16MM X_1516-40-316 X_DEPUY,10090190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ3 16MM X_1516-40-316 X_DEPUY,10090190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ3 18MM X_1516-40-318 X_DEPUY,10090191,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ3 18MM X_1516-40-318 X_DEPUY,10090191,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ3 20MM X_1516-40-320 X_DEPUY,10090192,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ3 20MM X_1516-40-320 X_DEPUY,10090192,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ3 5MM X_1516-40-305 X_DEPUY,10090193,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ3 5MM X_1516-40-305 X_DEPUY,10090193,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ4 14MM X_1516-40-414 X_DEPUY,10090194,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ4 14MM X_1516-40-414 X_DEPUY,10090194,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ4 16MM,10090195,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ4 16MM,10090195,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ4 18MM X_1516-40-418 X_DEPUY,10090196,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ4 18MM X_1516-40-418 X_DEPUY,10090196,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ4 20MM X_1516-40-420 X_DEPUY,10090197,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ4 20MM X_1516-40-420 X_DEPUY,10090197,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ5 12MM,10090198,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ5 12MM,10090198,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ5 16MM X_1516-40-516 X_DEPUY,10090199,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ5 16MM X_1516-40-516 X_DEPUY,10090199,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ5 18MM X_1516-40-518 X_DEPUY,10090200,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ5 18MM X_1516-40-518 X_DEPUY,10090200,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ5 20MM X_1516-40-520 X_DEPUY,10090201,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ5 20MM X_1516-40-520 X_DEPUY,10090201,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ6 18MM X_1516-40-618 X_DEPUY,10090202,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ6 18MM X_1516-40-618 X_DEPUY,10090202,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ6 20MM X_1516-40-620 X_DEPUY,10090203,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ6 20MM X_1516-40-620 X_DEPUY,10090203,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ7 14MM X_1516-40-714 X_DEPUY,10090204,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ7 14MM X_1516-40-714 X_DEPUY,10090204,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ7 18MM X_1516-40-718 X_DEPUY,10090205,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ7 18MM X_1516-40-718 X_DEPUY,10090205,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ7 20MM X_1516-40-720 X_DEPUY,10090206,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ7 20MM X_1516-40-720 X_DEPUY,10090206,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ8 12MM,10090207,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ8 12MM,10090207,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ8 14MM,10090208,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ8 14MM,10090208,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ8 16MM X_1516-40-816 X_DEPUY,10090209,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ8 16MM X_1516-40-816 X_DEPUY,10090209,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ8 18MM X_1516-40-818 X_DEPUY,10090210,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ8 18MM X_1516-40-818 X_DEPUY,10090210,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ8 20MM X_1516-40-820 X_DEPUY,10090211,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ8 20MM X_1516-40-820 X_DEPUY,10090211,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Amputation of toe,10090667,CDM,0761,RC,28820,CPT,,,,,,outpatient,facility,,,6437.00,1931.10,118.0,5471.45,,3978.07,,,percent of total billed charges,,,,,,,,,3141.26,,,percent of total billed charges,,,3246.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2735.72,,,percent of total billed charges,,,,,,,,,4827.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3218.5,,,percent of total billed charges,,,,,,,,,4827.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5471.45,,,percent of total billed charges,,,2961.02,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Amputation of toe,10090667,CDM,0761,RC,28820,CPT,05113,APC,,,,outpatient,facility,,,6437.00,1931.10,2984.48,7146.28,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6545.48,,,fee schedule,,,2984.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3173.71,,,fee schedule,,,7146.28,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6450.62,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,2984.48,,,fee schedule,,,3173.71,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,2984.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3173.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,3142.46,,,fee schedule,,,,,,,,
WC-Amputation of toe,10090667,CDM,0761,RC,28820,CPT,35,EAPG,,,,outpatient,facility,,,6437.00,1931.10,3109.33,6931.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6931.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5891.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4173.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4591.22,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Partial amputation of toe,10090668,CDM,0761,RC,28825,CPT,,,,,,outpatient,facility,,,6436.00,1930.80,118.0,5470.60,,3977.45,,,percent of total billed charges,,,,,,,,,3140.77,,,percent of total billed charges,,,3246.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2735.30,,,percent of total billed charges,,,,,,,,,4827.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3218.0,,,percent of total billed charges,,,,,,,,,4827.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5470.60,,,percent of total billed charges,,,2960.56,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Partial amputation of toe,10090668,CDM,0761,RC,28825,CPT,05113,APC,,,,outpatient,facility,,,6436.00,1930.80,2984.48,7146.28,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6545.48,,,fee schedule,,,2984.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3173.71,,,fee schedule,,,7146.28,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6450.62,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,2984.48,,,fee schedule,,,3173.71,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,2984.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3173.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,3142.46,,,fee schedule,,,,,,,,
WC-Partial amputation of toe,10090668,CDM,0761,RC,28825,CPT,35,EAPG,,,,outpatient,facility,,,6436.00,1930.80,3109.33,6931.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6931.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5891.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4173.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4591.22,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CUP ACET SZ F 60MM X_500-03-60F X_STRYKER,10092185,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACET SZ F 60MM X_500-03-60F X_STRYKER,10092185,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP RECON 3.5X84MM 6H,10092186,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2376.00,712.80,921.89,2019.60,,,,,,,,,,,,,,,,,,,,921.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1009.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1782.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1188.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2019.60,,,percent of total billed charges,,,1069.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP RECON 3.5X84MM 6H,10092186,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2376.00,712.80,1009.8,2019.60,,,,,,,,,,,,,service not payable,,,,,,,1198.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1009.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1782.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1188.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1782.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2019.60,,,percent of total billed charges,,,1092.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER CRT-D IS-1 INOGEN,10092187,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,28630.00,8589.00,11108.44,24335.5,,14028.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12024.6,,,percent of total billed charges,,Paid in addition to inpatient services ,11108.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14315.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24335.5,,,percent of total billed charges,,,12883.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER CRT-D IS-1 INOGEN,10092187,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,28630.00,8589.00,12024.6,24335.5,,14028.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12024.6,,,percent of total billed charges,,Paid in addition to outpatient services ,14440.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12167.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21472.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14315.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21472.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24335.5,,,percent of total billed charges,,,13169.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING MENSC OXF MED 8MM THK X_159580 X_BIOMET,10092190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4255.00,1276.50,1650.94,3616.75,,,,,,,,,,,,,,,,,,,,1650.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3191.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3616.75,,,percent of total billed charges,,,1914.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING MENSC OXF MED 8MM THK X_159580 X_BIOMET,10092190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4255.00,1276.50,1808.38,3616.75,,,,,,,,,,,,,service not payable,,,,,,,2146.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1808.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3191.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3191.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3616.75,,,percent of total billed charges,,,1957.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTERAN 11.5MMX30CM 125DEG LT X_71675239 X_SM,10092193,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTERAN 11.5MMX30CM 125DEG LT X_71675239 X_SM,10092193,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM 125D LFT 10MMX44CM,10092194,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM 125D LFT 10MMX44CM,10092194,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTERAN 10MMX46CM 125DEG LT X_71675521 X_SMIT,10092195,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTERAN 10MMX46CM 125DEG LT X_71675521 X_SMIT,10092195,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTERAN 11.5MMX30CM 130DEG LT X_71675283 X_SM,10092196,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTERAN 11.5MMX30CM 130DEG LT X_71675283 X_SM,10092196,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTERAN 11.5MMX44CM 130DEG LT X_71675297 X_SM,10092197,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12277.00,3683.10,4763.48,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4763.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10435.45,,,percent of total billed charges,,,5524.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTERAN 11.5MMX44CM 130DEG LT X_71675297 X_SM,10092197,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12277.00,3683.10,5156.34,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6192.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10435.45,,,percent of total billed charges,,,5647.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTERAN 11.5MMX46CM 130DEG LT X_71675299 X_SM,10092198,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12277.00,3683.10,4763.48,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4763.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10435.45,,,percent of total billed charges,,,5524.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTERAN 11.5MMX46CM 130DEG LT X_71675299 X_SM,10092198,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12277.00,3683.10,5156.34,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6192.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10435.45,,,percent of total billed charges,,,5647.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX30CM 130DEG LT X_71675506 X_SMITH NEPHEW,10092199,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX30CM 130DEG LT X_71675506 X_SMITH NEPHEW,10092199,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX40CM 130DEG LT X_71675520 X_SMITH NEPHEW,10092200,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX40CM 130DEG LT X_71675520 X_SMITH NEPHEW,10092200,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX46CM 130DEG LT X_71675522 X_SMITH NEPHEW,10092201,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX46CM 130DEG LT X_71675522 X_SMITH NEPHEW,10092201,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NIAL 11.5MMX44CM 130DEG RT X_71675298 X_SMITH NEPH,10092202,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12277.00,3683.10,4763.48,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4763.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10435.45,,,percent of total billed charges,,,5524.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIAL 11.5MMX44CM 130DEG RT X_71675298 X_SMITH NEPH,10092202,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12277.00,3683.10,5156.34,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6192.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10435.45,,,percent of total billed charges,,,5647.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NIAL 11.5MMX46CM 130DEG RT X_71675300 X_SMITH NEPH,10092203,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12277.00,3683.10,4763.48,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4763.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10435.45,,,percent of total billed charges,,,5524.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIAL 11.5MMX46CM 130DEG RT X_71675300 X_SMITH NEPH,10092203,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12277.00,3683.10,5156.34,10435.45,,6015.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5156.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6192.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5217.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9207.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6138.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9207.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10435.45,,,percent of total billed charges,,,5647.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX30CM 130DEG RT X_71675528 X_SMITH NEPHEW,10092204,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX30CM 130DEG RT X_71675528 X_SMITH NEPHEW,10092204,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX40CM 130DEG RT X_71675542 X_SMITH NEPHEW,10092205,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX40CM 130DEG RT X_71675542 X_SMITH NEPHEW,10092205,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX46CM 130DEG RT X_71675544 X_SMITH NEPHEW,10092206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX46CM 130DEG RT X_71675544 X_SMITH NEPHEW,10092206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX30CM 125DEG RT X_71675240 X_SMITH NEPH,10092207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX30CM 125DEG RT X_71675240 X_SMITH NEPH,10092207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTERAN 11.5MMX46CM 125DEG RT X_71675256 X_SM,10092208,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTERAN 11.5MMX46CM 125DEG RT X_71675256 X_SM,10092208,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 10MMX44CM 125DEG RT X_71675541 X_SMITH NEPHEW,10092209,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5509.00,1652.70,2137.49,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4682.65,,,percent of total billed charges,,,2479.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 10MMX44CM 125DEG RT X_71675541 X_SMITH NEPHEW,10092209,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5509.00,1652.70,2313.78,4682.65,,2699.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4682.65,,,percent of total billed charges,,,2534.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 11.5MMX42CM X_71653042 X_SMITH NEPH,10092210,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 11.5MMX42CM X_71653042 X_SMITH NEPH,10092210,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 10MMX38CM X_71653038 X_SMITH NEPHEW,10092211,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 10MMX38CM X_71653038 X_SMITH NEPHEW,10092211,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 10MMX36CM X_71653036 X_SMITH NEPHEW,10092212,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 10MMX36CM X_71653036 X_SMITH NEPHEW,10092212,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 10MMX34CM X_71653034 X_SMITH NEPHEW,10092213,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 10MMX34CM X_71653034 X_SMITH NEPHEW,10092213,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 10MMX30CM X_71653030 X_SMITH NEPHEW,10092214,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 10MMX30CM X_71653030 X_SMITH NEPHEW,10092214,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 11.5MMX42CM X_71653242 X_SMITH NEPH,10092215,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 11.5MMX42CM X_71653242 X_SMITH NEPH,10092215,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 11.5MMX40CM X_71653240 X_SMITH NEPH,10092216,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 11.5MMX40CM X_71653240 X_SMITH NEPH,10092216,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 11.5MMX34CM X_71653234 X_SMITH NEPH,10092217,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 11.5MMX34CM X_71653234 X_SMITH NEPH,10092217,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 13MMX42CM X_71653442 X_SMITH NEPHEW,10092218,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 13MMX42CM X_71653442 X_SMITH NEPHEW,10092218,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 13MMX40CM X_71653440 X_SMITH NEPHEW,10092219,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 13MMX40CM X_71653440 X_SMITH NEPHEW,10092219,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 13MMX36CM X_71653436 X_SMITH NEPHEW,10092220,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 13MMX36CM X_71653436 X_SMITH NEPHEW,10092220,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RETRO FEM 13MMX30CM X_71653430 X_SMITH NEPHEW,10092221,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RETRO FEM 13MMX30CM X_71653430 X_SMITH NEPHEW,10092221,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANGIO CATH 5F 65X.035CM X_M001314090 X_BOSTON SCIE,10092222,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 12MMX4 X_48824012 X_RTI BIOLOGICS,10092224,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 12MMX4 X_48824012 X_RTI BIOLOGICS,10092224,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE RAD TI POST5.5X70MM,10092230,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE RAD TI POST5.5X70MM,10092230,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 7.5X40MM,10092231,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 7.5X40MM,10092231,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 7.5X35MM,10092232,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 7.5X35MM,10092232,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SPINE XIA 3 53-73MM,10092233,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SPINE XIA 3 53-73MM,10092233,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI 3.5X30MM X_48552030 X_STRYKER,10092236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI 3.5X30MM X_48552030 X_STRYKER,10092236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CROSSLINK CONNECTOR 32MM X_48551074 X_STRYKE,10092237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CROSSLINK CONNECTOR 32MM X_48551074 X_STRYKE,10092237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7X55MM,10092238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7X55MM,10092238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7X70MM,10092239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7X70MM,10092239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 23.5D TECNIS SYMFONY X_ZXT375-23.5 X_ABBOTT,10092240,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 23.5D TECNIS SYMFONY X_ZXT375-23.5 X_ABBOTT,10092240,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
CATH USHER TAPERD TIP 130CM,10092241,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1558.00,467.40,662.15,1324.3,,962.84,,,percent of total billed charges,,,,,,,,service not payable,760.30,,,percent of total billed charges,,,785.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,662.15,,,percent of total billed charges,,,,,,,,,1168.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,779.0,,,percent of total billed charges,,,,,,,,service not payable,1168.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1324.3,,,percent of total billed charges,,,716.68,,,percent of total billed charges,,,,,,,,,1012.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1012.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE COTTON ANATOMIC 16X5.5MM X_AR-8948W-1655 X_A,10092242,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE COTTON ANATOMIC 16X5.5MM X_AR-8948W-1655 X_A,10092242,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL FB CEM SZ6,10092243,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL FB CEM SZ6,10092243,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM STD SZ 16 135D 150MM,10092244,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM STD SZ 16 135D 150MM,10092244,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT FEM KNEE LFT SZ4N,10092245,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT FEM KNEE LFT SZ4N,10092245,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHNBX 9MMX39MMX13CM,10092246,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GR VIABAHN 7MMX2.5X120CM,10092247,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10999.00,3299.70,4267.61,9349.15,,5389.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4619.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4267.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4674.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8249.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5499.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9349.15,,,percent of total billed charges,,,4949.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GR VIABAHN 7MMX2.5X120CM,10092247,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10999.00,3299.70,4619.58,9349.15,,5389.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4619.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5547.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4674.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8249.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5499.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8249.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9349.15,,,percent of total billed charges,,,5059.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP SS 2.7X16MM,10092248,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP SS 2.7X16MM,10092248,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE POST DISTAL FIBULA 4H X_AR-8963PLL-04 X_ARTH,10092249,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE POST DISTAL FIBULA 4H X_AR-8963PLL-04 X_ARTH,10092249,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PIP DART 2.5X30MM X_AR-4154PS-3010 X_ARTHREX,10092250,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2601.00,780.30,1009.19,2210.85,,,,,,,,,,,,,,,,,,,,1009.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2210.85,,,percent of total billed charges,,,1170.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PIP DART 2.5X30MM X_AR-4154PS-3010 X_ARTHREX,10092250,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,,,,,,,,,,,,service not payable,,,,,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEEDLE STIMUPLEX ULTRA 20G 4IN,10092251,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,81.00,24.30,31.43,68.85,,,,,,,,,,,,,,,,,,,,31.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,60.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.85,,,percent of total billed charges,,,36.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE STIMUPLEX ULTRA 20G 4IN,10092251,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,81.00,24.30,34.42,68.85,,,,,,,,,,,,,service not payable,,,,,,,40.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,34.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,60.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,40.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,60.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,68.85,,,percent of total billed charges,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VASC QUAD 6FR 5MM 92CM RP X_D6-DR-005-RT X_ST,10092253,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,742.00,222.60,315.35,630.70,,458.56,,,percent of total billed charges,,,,,,,,service not payable,362.10,,,percent of total billed charges,,,374.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.35,,,percent of total billed charges,,,,,,,,,556.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.0,,,percent of total billed charges,,,,,,,,service not payable,556.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,630.70,,,percent of total billed charges,,,341.32,,,percent of total billed charges,,,,,,,,,482.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,482.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH PANEL TITANIUM .1X1X80X80,10092254,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3352.00,1005.60,1300.58,2849.20,,,,,,,,,,,,,,,,,,,,1300.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1424.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2514.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1676.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2849.20,,,percent of total billed charges,,,1508.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH PANEL TITANIUM .1X1X80X80,10092254,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3352.00,1005.60,1424.60,2849.20,,,,,,,,,,,,,service not payable,,,,,,,1690.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1424.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2514.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1676.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2514.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2849.20,,,percent of total billed charges,,,1541.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
YPLATE 1.5 MED 5H MANDIBLE X_25-320-70-09 X_KLS MA,10092255,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,707.00,212.10,274.32,600.95,,,,,,,,,,,,,,,,,,,,274.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,530.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,353.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.95,,,percent of total billed charges,,,318.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
YPLATE 1.5 MED 5H MANDIBLE X_25-320-70-09 X_KLS MA,10092255,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,707.00,212.10,300.47,600.95,,,,,,,,,,,,,service not payable,,,,,,,356.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,300.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,530.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,353.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,530.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,600.95,,,percent of total billed charges,,,325.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DOUBLE Y SHAPE REG CP X_25-573-06-91 X_KLS M,10092256,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DOUBLE Y SHAPE REG CP X_25-573-06-91 X_KLS M,10092256,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CROSS DRIVE 2.3X5MM X_25-873-45-91 X_KL,10092257,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,289.00,86.70,112.13,245.65,,,,,,,,,,,,,,,,,,,,112.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,216.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.65,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CROSS DRIVE 2.3X5MM X_25-873-45-91 X_KL,10092257,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,289.00,86.70,122.82,245.65,,,,,,,,,,,,,service not payable,,,,,,,145.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,122.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,216.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,144.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,216.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,245.65,,,percent of total billed charges,,,132.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LOCKING ANGLE 32H 2MM X_50-778-32-09 X_KLS M,10092258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5102.00,1530.60,1979.58,4336.70,,2499.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2142.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1979.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2168.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3826.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2551.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4336.70,,,percent of total billed charges,,,2295.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LOCKING ANGLE 32H 2MM X_50-778-32-09 X_KLS M,10092258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5102.00,1530.60,2142.84,4336.70,,2499.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2142.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2573.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2168.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3826.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2551.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3826.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4336.70,,,percent of total billed charges,,,2346.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HANDLE SCREW BLADES 2.0MM 2.7MM X_25-406-99-07 X_K,10092259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1429.00,428.70,554.45,1214.65,,,,,,,,,,,,,,,,,,,,554.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1071.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,714.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1214.65,,,percent of total billed charges,,,643.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HANDLE SCREW BLADES 2.0MM 2.7MM X_25-406-99-07 X_K,10092259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1429.00,428.70,607.32,1214.65,,,,,,,,,,,,,service not payable,,,,,,,720.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,607.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1071.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,714.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1071.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1214.65,,,percent of total billed charges,,,657.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUTTER PLATE LOCKING F/2MM/3MM X_25-420-20-07 X_KL,10092260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5521.00,1656.30,2142.15,4692.85,,2705.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2318.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2142.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2346.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4140.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2760.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4692.85,,,percent of total billed charges,,,2484.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUTTER PLATE LOCKING F/2MM/3MM X_25-420-20-07 X_KL,10092260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5521.00,1656.30,2318.82,4692.85,,2705.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2318.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2784.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2346.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4140.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2760.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4140.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4692.85,,,percent of total billed charges,,,2539.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LOCKING 32H 0.6MM X_50-789-82-09 X_KLS MARTI,10092261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,331.00,99.30,128.43,281.35,,,,,,,,,,,,,,,,,,,,128.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,,148.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LOCKING 32H 0.6MM X_50-789-82-09 X_KLS MARTI,10092261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,331.00,99.30,140.67,281.35,,,,,,,,,,,,,service not payable,,,,,,,166.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,248.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,,152.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATHRECTOMY 1.5MM 145CM X_DBP-150SOLID145 X_CARDIOV,10092769,CDM,0278,RC,C1724,HCPCS,,,,,,inpatient,facility,,,11131.00,3339.30,4318.83,9461.35,,5454.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4675.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4318.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4730.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8348.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9461.35,,,percent of total billed charges,,,5008.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATHRECTOMY 1.5MM 145CM X_DBP-150SOLID145 X_CARDIOV,10092769,CDM,0278,RC,C1724,HCPCS,,,,,,outpatient,facility,,,11131.00,3339.30,4675.02,9461.35,,5454.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4675.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5614.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4730.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9461.35,,,percent of total billed charges,,,5120.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM BALLOON EBUS,10092770,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.28,138.55,,100.73,,,percent of total billed charges,,,,,,,,service not payable,79.54,,,percent of total billed charges,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.28,,,percent of total billed charges,,,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,105.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,105.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SUPERA 5.5X80MM X_S-55-080-120-P6 X_ABBOTT V,10093109,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SUPERA 5.5X80MM X_S-55-080-120-P6 X_ABBOTT V,10093109,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL GLOBAL 18X56MM,10093110,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7050.00,2115.00,2735.40,5992.5,,3454.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2961.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2735.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2996.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5287.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3525.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5992.5,,,percent of total billed charges,,,3172.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL GLOBAL 18X56MM,10093110,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7050.00,2115.00,2961.0,5992.5,,3454.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2961.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3556.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2996.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5287.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3525.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5287.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5992.5,,,percent of total billed charges,,,3243.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE ANCHOR NO 2 3X12.7MM,10093112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE ANCHOR NO 2 3X12.7MM,10093112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DRAINAGE 10F 25CM STD LP,10093116,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,365.00,109.50,155.13,310.25,,225.57,,,percent of total billed charges,,,,,,,,service not payable,178.12,,,percent of total billed charges,,,184.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,155.13,,,percent of total billed charges,,,,,,,,,273.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,182.5,,,percent of total billed charges,,,,,,,,service not payable,273.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,310.25,,,percent of total billed charges,,,167.90,,,percent of total billed charges,,,,,,,,,237.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,237.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LipoFit by NMR,10094097,CDM,0300,RC,83704,CPT,,,,,,outpatient,facility,,,81.00,24.30,32.48,81.0,,81.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,33.51,,,fee schedule,,,81.0,,,fee schedule,,,71.30,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,70.77,,,fee schedule,,,32.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",34.18,,,fee schedule,,,77.27,,,fee schedule,,,,,,,,,33.51,,,fee schedule,,,,,,,,,43.82,,,fee schedule,,,69.75,,,fee schedule,,,60.75,,,percent of total billed charges,,,33.51,,,fee schedule,,,32.48,,,fee schedule,,,34.18,,,fee schedule,,,51.53,,,fee schedule,,,33.51,,,fee schedule,,,60.75,,,percent of total billed charges,,,,,,,,,34.18,,,fee schedule,,,,,,,,,68.85,,,percent of total billed charges,,,37.26,,,percent of total billed charges,,,,,,,,,37.61,,,fee schedule,,,33.51,,,fee schedule,,,,,,,,,33.16,,,fee schedule,,,33.51,,,fee schedule,,,,,,,,,33.84,,,fee schedule,,,,,,,,
LipoFit by NMR,10094097,CDM,0300,RC,83704,CPT,401,EAPG,,,,outpatient,facility,,,81.00,24.30,33.20,115.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,60.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.20,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.20,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.20,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,104.78,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,115.26,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Episiotomy or vaginal repair by other than attendi,10094168,CDM,0450,RC,59300,CPT,,,,,,outpatient,facility,,,5504.00,1651.20,774.0,4678.40,,3401.47,,,percent of total billed charges,,,,,,,,,2685.95,,,percent of total billed charges,,,2776.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4128.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4128.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4678.40,,,percent of total billed charges,,,2531.84,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Episiotomy or vaginal repair by other than attendi,10094168,CDM,0450,RC,59300,CPT,05414,APC,,,,outpatient,facility,,,5504.00,1651.20,1462.31,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,1462.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,1462.31,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,1462.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Episiotomy or vaginal repair by other than attendi,10094168,CDM,0450,RC,59300,CPT,205,EAPG,,,,outpatient,facility,,,5504.00,1651.20,2464.07,5913.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5913.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5026.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2464.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2464.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2464.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2866.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3152.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BALLOON CATH PTA 6X200MM X_H74939171032010 X_BARD,10094175,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1284.00,385.20,545.70,1091.40,,793.51,,,percent of total billed charges,,,,,,,,service not payable,626.59,,,percent of total billed charges,,,647.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,,,,,,,,963.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,642.0,,,percent of total billed charges,,,,,,,,service not payable,963.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1091.40,,,percent of total billed charges,,,590.64,,,percent of total billed charges,,,,,,,,,834.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,834.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 6X150MMX130CM,10094176,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 6X150MMX130CM,10094176,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPR FT 7.0 XL 75MM LGT,10094178,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3039.00,911.70,1179.13,2583.15,,,,,,,,,,,,,,,,,,,,1179.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2279.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.15,,,percent of total billed charges,,,1367.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPR FT 7.0 XL 75MM LGT,10094178,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3039.00,911.70,1291.58,2583.15,,,,,,,,,,,,,service not payable,,,,,,,1532.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2279.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2279.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2583.15,,,percent of total billed charges,,,1397.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPRSS FTHR 7X60MM,10094179,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPRSS FTHR 7X60MM,10094179,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PACER U PR 1456Q/86 X_ST JUDE,10094182,CDM,0275,RC,C1898,HCPCS,,,,,,inpatient,facility,,,9298.00,2789.40,3607.62,7903.30,,4556.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3905.16,,,percent of total billed charges,,Paid in addition to inpatient services ,3607.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3951.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6973.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4649.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7903.30,,,percent of total billed charges,,,4184.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACER U PR 1456Q/86 X_ST JUDE,10094182,CDM,0275,RC,C1898,HCPCS,,,,,,outpatient,facility,,,9298.00,2789.40,3905.16,7903.30,,4556.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3905.16,,,percent of total billed charges,,Paid in addition to outpatient services ,4689.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3951.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6973.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4649.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6973.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7903.30,,,percent of total billed charges,,,4277.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 12X55MM,10094183,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 12X55MM,10094183,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER 13X30MM 4DEG X_48370134 X_STRYKER,10094184,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER 13X30MM 4DEG X_48370134 X_STRYKER,10094184,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM REDAPT SZ18 190MM X_71354467 X_SMITH NEPH,10094185,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,22583.00,6774.90,8762.20,19195.55,,11065.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9484.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8762.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9597.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16937.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11291.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19195.55,,,percent of total billed charges,,,10162.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM REDAPT SZ18 190MM X_71354467 X_SMITH NEPH,10094185,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,22583.00,6774.90,9484.86,19195.55,,11065.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9484.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11390.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9597.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16937.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11291.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16937.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19195.55,,,percent of total billed charges,,,10388.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X70MM X_222870 X_SMITH NEPHEW,10094186,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X70MM X_222870 X_SMITH NEPHEW,10094186,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CEM SZ4,10094188,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CEM SZ4,10094188,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER QUAD CRT-P X_W4TR01 X_MEDTRONIC USA INC,10094189,CDM,0275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,17965.00,5389.50,6970.42,15270.25,,8802.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7545.30,,,percent of total billed charges,,Paid in addition to inpatient services ,6970.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7635.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13473.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8982.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15270.25,,,percent of total billed charges,,,8084.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER QUAD CRT-P X_W4TR01 X_MEDTRONIC USA INC,10094189,CDM,0275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,17965.00,5389.50,7545.30,15270.25,,8802.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7545.30,,,percent of total billed charges,,Paid in addition to outpatient services ,9061.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7635.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13473.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8982.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13473.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15270.25,,,percent of total billed charges,,,8263.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Programming Leadless Device Eval,10094474,CDM,0481,RC,93279,CPT,,,,,,outpatient,facility,,,120.00,36.00,36.79,102.0,,49.31,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,36.79,,,fee schedule,,,60.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.0,,,percent of total billed charges,,,,,,,,,90.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.0,,,percent of total billed charges,,,,,,,,,90.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.0,,,percent of total billed charges,,,55.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Programming Leadless Device Eval,10094474,CDM,0481,RC,93279,CPT,05741,APC,,,,outpatient,facility,,,120.00,36.00,34.30,82.13,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,75.22,,,fee schedule,,,34.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",36.48,,,fee schedule,,,82.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,74.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,34.30,,,fee schedule,,,36.48,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,34.30,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",36.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,36.11,,,fee schedule,,,,,,,,
Programming Leadless Device Eval,10094474,CDM,0481,RC,93279,CPT,488,EAPG,,,,outpatient,facility,,,120.00,36.00,52.57,109.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,93.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,91.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,100.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Programming Leadless Device Eval,10094477,CDM,0481,RC,93279,CPT,,,,,,outpatient,facility,,,120.00,36.00,36.79,102.0,,49.31,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,36.79,,,fee schedule,,,60.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.0,,,percent of total billed charges,,,,,,,,,90.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.0,,,percent of total billed charges,,,,,,,,,90.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.0,,,percent of total billed charges,,,55.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Programming Leadless Device Eval,10094477,CDM,0481,RC,93279,CPT,05741,APC,,,,outpatient,facility,,,120.00,36.00,34.30,82.13,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,75.22,,,fee schedule,,,34.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",36.48,,,fee schedule,,,82.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,74.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,34.30,,,fee schedule,,,36.48,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,34.30,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",36.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,36.11,,,fee schedule,,,,,,,,
Programming Leadless Device Eval,10094477,CDM,0481,RC,93279,CPT,488,EAPG,,,,outpatient,facility,,,120.00,36.00,52.57,109.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,93.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,91.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,100.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ROD CONN 8X200MM EXT FIX X_5028-8-200 X_STRYKER OR,10094575,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1879.00,563.70,729.05,1597.15,,,,,,,,,,,,,,,,,,,,729.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,798.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1409.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,939.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.15,,,percent of total billed charges,,,845.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONN 8X200MM EXT FIX X_5028-8-200 X_STRYKER OR,10094575,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1879.00,563.70,798.57,1597.15,,,,,,,,,,,,,service not payable,,,,,,,947.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,798.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1409.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,939.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1409.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1597.15,,,percent of total billed charges,,,864.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CRV SC EXT FIX 8X174MM X_5028-7-030 X_STRYKER,10094576,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1267.00,380.10,491.60,1076.95,,,,,,,,,,,,,,,,,,,,491.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,950.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,633.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1076.95,,,percent of total billed charges,,,570.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CRV SC EXT FIX 8X174MM X_5028-7-030 X_STRYKER,10094576,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1267.00,380.10,538.48,1076.95,,,,,,,,,,,,,service not payable,,,,,,,639.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,538.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,950.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,633.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,950.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1076.95,,,percent of total billed charges,,,582.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF APEX S/D 3/5X20X120MM X_5026-8-120 X_STRY,10094577,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,674.00,202.20,261.51,572.90,,,,,,,,,,,,,,,,,,,,261.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,505.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,337.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.90,,,percent of total billed charges,,,303.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF APEX S/D 3/5X20X120MM X_5026-8-120 X_STRY,10094577,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,674.00,202.20,286.45,572.90,,,,,,,,,,,,,service not payable,,,,,,,339.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,286.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,505.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,337.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,505.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,572.90,,,percent of total billed charges,,,310.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 24FR 34X30X150MM X_VAMF3430C150TU X_ME,10094578,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,60631.00,18189.30,23524.83,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,23524.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51536.35,,,percent of total billed charges,,,27283.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 24FR 34X30X150MM X_VAMF3430C150TU X_ME,10094578,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,60631.00,18189.30,25465.02,51536.35,,29709.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25465.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,30582.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25768.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45473.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45473.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51536.35,,,percent of total billed charges,,,27890.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5X55MM X_48146555 X_STRYKER,10094580,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5X55MM X_48146555 X_STRYKER,10094580,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINAL XIA PRECUT 40X4.5MM,10094581,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINAL XIA PRECUT 40X4.5MM,10094581,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK WEDGE4D 10X11X25MM,10094582,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK WEDGE4D 10X11X25MM,10094582,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SPINE XIA POST XL,10094583,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SPINE XIA POST XL,10094583,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SPINE PL SHORT 9X25X9MM,10094584,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SPINE PL SHORT 9X25X9MM,10094584,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SPINE PL SHORT 7X25X9MM,10094585,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SPINE PL SHORT 7X25X9MM,10094585,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE RADIUS POST 5.5X60MM,10094586,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE RADIUS POST 5.5X60MM,10094586,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER MICRA 23FR 55.7CM,10094587,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.78,2229.55,,1621.01,,,percent of total billed charges,,,,,,,,service not payable,1280.02,,,percent of total billed charges,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.78,,,percent of total billed charges,,,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,1704.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1704.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER MICRA TRANSCATHETER,10094588,CDM,0275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,35242.00,10572.60,13673.90,29955.70,,17268.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14801.64,,,percent of total billed charges,,Paid in addition to inpatient services ,13673.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14977.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26431.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17621.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29955.70,,,percent of total billed charges,,,15858.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER MICRA TRANSCATHETER,10094588,CDM,0275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,35242.00,10572.60,14801.64,29955.70,,17268.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14801.64,,,percent of total billed charges,,Paid in addition to outpatient services ,17776.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14977.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26431.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17621.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26431.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29955.70,,,percent of total billed charges,,,16211.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE AUGMENT ACETAB 46X15MM X_5096-4615 X_STRYKER,10094589,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7043.00,2112.90,2732.68,5986.55,,3451.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2958.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2732.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2993.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5282.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5986.55,,,percent of total billed charges,,,3169.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE AUGMENT ACETAB 46X15MM X_5096-4615 X_STRYKER,10094589,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7043.00,2112.90,2958.06,5986.55,,3451.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2958.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3552.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2993.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5282.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5282.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5986.55,,,percent of total billed charges,,,3239.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL FB CEM SZ7,10094590,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL FB CEM SZ7,10094590,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB 17.5MM SZ 2,10094591,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB 17.5MM SZ 2,10094591,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF-Destruction benign lesions other than skin tag,10094837,CDM,0761,RC,17110,CPT,,,,,,outpatient,facility,,,404.00,121.20,118.0,343.40,,249.67,,,percent of total billed charges,,,,,,,,,197.15,,,percent of total billed charges,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.70,,,percent of total billed charges,,,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.0,,,percent of total billed charges,,,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
BCF-Destruction benign lesions other than skin tag,10094837,CDM,0761,RC,17110,CPT,05051,APC,,,,outpatient,facility,,,404.00,121.20,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
BCF-Destruction benign lesions other than skin tag,10094837,CDM,0761,RC,17110,CPT,3,EAPG,,,,outpatient,facility,,,404.00,121.20,240.16,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DEFIB DYNAGEN EL DR DUAL CHMBR,10094887,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,32455.00,9736.50,12592.54,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13631.1,,,percent of total billed charges,,Paid in addition to inpatient services ,12592.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27586.75,,,percent of total billed charges,,,14604.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB DYNAGEN EL DR DUAL CHMBR,10094887,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,32455.00,9736.50,13631.1,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13631.1,,,percent of total billed charges,,Paid in addition to outpatient services ,16370.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27586.75,,,percent of total billed charges,,,14929.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE ASAHI 12 0.014 300CM X_82903-02 X_ABBOTT,10094890,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,422.09,,,percent of total billed charges,,,,,,,,service not payable,333.30,,,percent of total billed charges,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VASC STINGRAY 185CM,10094891,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2684.00,805.20,1140.7,2281.40,,1658.71,,,percent of total billed charges,,,,,,,,service not payable,1309.79,,,percent of total billed charges,,,1353.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1140.7,,,percent of total billed charges,,,,,,,,,2013.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1342.0,,,percent of total billed charges,,,,,,,,service not payable,2013.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2281.40,,,percent of total billed charges,,,1234.64,,,percent of total billed charges,,,,,,,,,1744.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1744.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TFN FEM PROX GOLD 90MM,10094892,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3816.00,1144.80,1480.61,3243.60,,,,,,,,,,,,,,,,,,,,1480.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1621.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2862.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1908.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3243.60,,,percent of total billed charges,,,1717.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TFN FEM PROX GOLD 90MM,10094892,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3816.00,1144.80,1621.8,3243.60,,,,,,,,,,,,,service not payable,,,,,,,1924.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1621.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2862.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1908.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2862.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3243.60,,,percent of total billed charges,,,1755.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RAD LCK 2X2.3X2.7MM 76MM,10094893,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3614.00,1084.20,1402.23,3071.90,,,,,,,,,,,,,,,,,,,,1402.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1535.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2710.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1807.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3071.90,,,percent of total billed charges,,,1626.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RAD LCK 2X2.3X2.7MM 76MM,10094893,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3614.00,1084.20,1535.95,3071.90,,,,,,,,,,,,,service not payable,,,,,,,1822.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1535.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2710.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1807.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2710.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3071.90,,,percent of total billed charges,,,1662.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFNA CANN 125D 11X170MM,10094894,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6285.00,1885.50,2438.58,5342.25,,3079.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2639.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2438.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2671.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4713.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5342.25,,,percent of total billed charges,,,2828.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFNA CANN 125D 11X170MM,10094894,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6285.00,1885.50,2639.70,5342.25,,3079.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2639.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3170.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2671.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4713.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4713.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5342.25,,,percent of total billed charges,,,2891.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 2.5X26MM X_141-2526 X_STRYKER,10094895,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1993.00,597.90,773.28,1694.05,,,,,,,,,,,,,,,,,,,,773.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1494.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,996.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1694.05,,,percent of total billed charges,,,896.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 2.5X26MM X_141-2526 X_STRYKER,10094895,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1993.00,597.90,847.02,1694.05,,,,,,,,,,,,,service not payable,,,,,,,1005.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,847.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1494.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,996.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1494.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1694.05,,,percent of total billed charges,,,916.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE FIXATION HAMMERTOE MD,10094896,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6523.00,1956.90,2530.92,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2530.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5544.55,,,percent of total billed charges,,,2935.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE FIXATION HAMMERTOE MD,10094896,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6523.00,1956.90,2739.66,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3290.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5544.55,,,percent of total billed charges,,,3000.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CEM SZ4 LFT 62.5X60.3,10094898,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CEM SZ4 LFT 62.5X60.3,10094898,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA 3 PEGS P2 X_NX042 X_AESCULAP,10094899,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA 3 PEGS P2 X_NX042 X_AESCULAP,10094899,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 4.0X54MM X_AR-8740-54PTS X_ARTHREX I,10094900,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 4.0X54MM X_AR-8740-54PTS X_ARTHREX I,10094900,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOW PROF TI 5.5MMX55MM,10094901,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOW PROF TI 5.5MMX55MM,10094901,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD 45MM TI X_481321045 X_STRYKER,10094902,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD 45MM TI X_481321045 X_STRYKER,10094902,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LipoFit by NMR-Lipid,10095111,CDM,0300,RC,80061,CPT,,,,,XU  ,outpatient,facility,,,34.00,10.20,12.72,34.0,,34.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.12,,,fee schedule,,,34.0,,,fee schedule,,,27.93,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.72,,,fee schedule,,,12.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.38,,,fee schedule,,,30.26,,,fee schedule,,,,,,,,,13.12,,,fee schedule,,,,,,,,,17.27,,,fee schedule,,,27.32,,,fee schedule,,,25.5,,,percent of total billed charges,,,13.12,,,fee schedule,,,12.72,,,fee schedule,,,13.38,,,fee schedule,,,20.31,,,fee schedule,,,13.12,,,fee schedule,,,25.5,,,percent of total billed charges,,,12.72,,,fee schedule,,,13.38,,,fee schedule,,,,,,,,,28.90,,,percent of total billed charges,,,15.64,,,percent of total billed charges,,,,,,,,,14.73,,,fee schedule,,,13.12,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,13.12,,,fee schedule,,,,,,,,,13.25,,,fee schedule,,,,,,,,
LipoFit by NMR-Lipid,10095111,CDM,0300,RC,80061,CPT,403,EAPG,,,XU  ,outpatient,facility,,,34.00,10.20,10.64,51.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,28.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,47.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,51.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WIRE ASAHI XTA 300CM STR BX/5,10096096,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,422.09,,,percent of total billed charges,,,,,,,,service not payable,333.30,,,percent of total billed charges,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE STINGRAY 0.014INX145CM,10096097,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,804.00,241.20,341.70,683.40,,496.87,,,percent of total billed charges,,,,,,,,service not payable,392.35,,,percent of total billed charges,,,405.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,341.70,,,percent of total billed charges,,,,,,,,,603.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,402.0,,,percent of total billed charges,,,,,,,,service not payable,603.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,683.40,,,percent of total billed charges,,,369.84,,,percent of total billed charges,,,,,,,,,522.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,522.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL LOCKING LP 3.0X24MM,10096098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL LOCKING LP 3.0X24MM,10096098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL LOCKING LP 3.0X30MM,10096099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL LOCKING LP 3.0X30MM,10096099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TI LOW PROFILE 3X32MM X_AR-8933V-32 X_ARTHRE,10096100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TI LOW PROFILE 3X32MM X_AR-8933V-32 X_ARTHRE,10096100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLY TI 7.5X45.0MM,10096101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLY TI 7.5X45.0MM,10096101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PEEK 0D 8.0X25.0MM,10096102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PEEK 0D 8.0X25.0MM,10096102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE GRAFT VITOSS 10ML MORSEL 1-4MM X_2102-0031 X_,10096103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4075.00,1222.50,1581.10,3463.75,,,,,,,,,,,,,,,,,,,,1581.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1731.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3056.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2037.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3463.75,,,percent of total billed charges,,,1833.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE GRAFT VITOSS 10ML MORSEL 1-4MM X_2102-0031 X_,10096103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4075.00,1222.50,1731.88,3463.75,,,,,,,,,,,,,service not payable,,,,,,,2055.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1731.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3056.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2037.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3056.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3463.75,,,percent of total billed charges,,,1874.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL FB CEM SZ3,10096104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL FB CEM SZ3,10096104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL FB CEM SZ2,10096105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13277.00,3983.10,5151.48,11285.45,,6505.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5576.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5151.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5642.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9957.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6638.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11285.45,,,percent of total billed charges,,,5974.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL FB CEM SZ2,10096105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13277.00,3983.10,5576.34,11285.45,,6505.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5576.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6696.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5642.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9957.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6638.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9957.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11285.45,,,percent of total billed charges,,,6107.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT G2 CONST SZ1-2 15MM X_71420964 X_SMITH NEPH,10096106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT G2 CONST SZ1-2 15MM X_71420964 X_SMITH NEPH,10096106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6FR 4.0MM,10096107,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6FR IL4,10096108,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6F 4.5MM X_40-6376 X_TERUMO M,10096109,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6F IL3.75,10096110,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6F IR 2,10096111,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6F IR 1,10096112,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE HEARTRAIL 6F IR2 SH X_40-6385 X_TERUMO,10096113,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STINGRAY LP 3.2FR 135CM,10096114,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,7521.00,2256.30,3196.43,6392.85,,4647.98,,,percent of total billed charges,,,,,,,,service not payable,3670.25,,,percent of total billed charges,,,3793.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3196.43,,,percent of total billed charges,,,,,,,,,5640.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3760.5,,,percent of total billed charges,,,,,,,,service not payable,5640.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6392.85,,,percent of total billed charges,,,3459.66,,,percent of total billed charges,,,,,,,,,4888.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4888.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SUPRACOND 14X420MM X_1826-1442S X_STRYKER ORT,10096115,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5416.00,1624.80,2101.41,4603.60,,2653.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2274.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2101.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4062.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2708.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4603.60,,,percent of total billed charges,,,2437.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SUPRACOND 14X420MM X_1826-1442S X_STRYKER ORT,10096115,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5416.00,1624.80,2274.72,4603.60,,2653.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2274.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2731.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4062.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2708.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4062.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4603.60,,,percent of total billed charges,,,2491.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NLK HEXALOBE 2.7X10MM X_30-3-0344-S X_ACUMED,10096116,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,591.00,177.30,229.31,502.35,,,,,,,,,,,,,,,,,,,,229.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,443.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,295.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.35,,,percent of total billed charges,,,265.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NLK HEXALOBE 2.7X10MM X_30-3-0344-S X_ACUMED,10096116,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,591.00,177.30,251.17,502.35,,,,,,,,,,,,,service not payable,,,,,,,298.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,251.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,443.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,295.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,443.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,502.35,,,percent of total billed charges,,,271.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ACU-LOC WRST SPAN LNG X_7006-1190N-S X_ACUME,10096117,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3327.00,998.10,1290.88,2827.95,,,,,,,,,,,,,,,,,,,,1290.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2495.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1663.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2827.95,,,percent of total billed charges,,,1497.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ACU-LOC WRST SPAN LNG X_7006-1190N-S X_ACUME,10096117,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3327.00,998.10,1413.97,2827.95,,,,,,,,,,,,,service not payable,,,,,,,1678.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1413.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2495.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1663.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2495.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2827.95,,,percent of total billed charges,,,1530.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL WIDE LFT X_54-2593 X_STRYKER ORTHOPAE,10096118,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3133.00,939.90,1215.60,2663.05,,,,,,,,,,,,,,,,,,,,1215.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1331.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2349.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1566.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2663.05,,,percent of total billed charges,,,1409.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL WIDE LFT X_54-2593 X_STRYKER ORTHOPAE,10096118,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3133.00,939.90,1331.52,2663.05,,,,,,,,,,,,,service not payable,,,,,,,1580.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1331.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2349.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1566.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2349.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2663.05,,,percent of total billed charges,,,1441.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT HUMN TISS PRESHAPED 10MM,10096292,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13375.00,4012.50,5189.5,11368.75,,6553.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5617.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5189.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5684.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10031.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6687.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11368.75,,,percent of total billed charges,,,6018.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT HUMN TISS PRESHAPED 10MM,10096292,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13375.00,4012.50,5617.5,11368.75,,6553.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5617.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6746.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5684.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10031.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6687.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10031.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11368.75,,,percent of total billed charges,,,6152.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN 9.0MMX34CM RT X_71640532 X_SMITH NEPHE,10096293,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9639.00,2891.70,3739.93,8193.15,,4723.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4048.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3739.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4096.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8193.15,,,percent of total billed charges,,,4337.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN 9.0MMX34CM RT X_71640532 X_SMITH NEPHE,10096293,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9639.00,2891.70,4048.38,8193.15,,4723.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4048.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4861.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4096.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8193.15,,,percent of total billed charges,,,4433.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ4 6MM,10096294,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ4 6MM,10096294,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LAG TI 2.3X30MM X_AR-13120T-30C X_ARTHR,10096295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,632.00,189.60,245.22,537.20,,,,,,,,,,,,,,,,,,,,245.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,474.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,316.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.20,,,percent of total billed charges,,,284.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LAG TI 2.3X30MM X_AR-13120T-30C X_ARTHR,10096295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,632.00,189.60,268.60,537.20,,,,,,,,,,,,,service not payable,,,,,,,318.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,268.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,474.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,316.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,474.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,537.20,,,percent of total billed charges,,,290.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CANN LAG TI 3X10MM X_AR-8933-10PT X_ARTHR,10096296,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CANN LAG TI 3X10MM X_AR-8933-10PT X_ARTHR,10096296,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CANN LAG TI 3X12MM X_AR-8933-12PT X_ARTHR,10096297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CANN LAG TI 3X12MM X_AR-8933-12PT X_ARTHR,10096297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CANN LAG TI 3X14MM X_AR-8933-14PT X_ARTHR,10096298,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CANN LAG TI 3X14MM X_AR-8933-14PT X_ARTHR,10096298,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL WIDE LFT 2.7MM X_54-25293 X_STRYKER O,10096299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3133.00,939.90,1215.60,2663.05,,,,,,,,,,,,,,,,,,,,1215.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1331.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2349.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1566.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2663.05,,,percent of total billed charges,,,1409.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL WIDE LFT 2.7MM X_54-25293 X_STRYKER O,10096299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3133.00,939.90,1331.52,2663.05,,,,,,,,,,,,,service not payable,,,,,,,1580.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1331.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2349.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1566.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2349.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2663.05,,,percent of total billed charges,,,1441.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK HEXALOBE 2.7X12MM X_30-0326-S X_ACCUMED,10096300,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,842.00,252.60,326.70,715.70,,,,,,,,,,,,,,,,,,,,326.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.70,,,percent of total billed charges,,,378.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK HEXALOBE 2.7X12MM X_30-0326-S X_ACCUMED,10096300,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,842.00,252.60,357.85,715.70,,,,,,,,,,,,,service not payable,,,,,,,424.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,631.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,715.70,,,percent of total billed charges,,,387.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK HEXALOBE 2.7X14MM X_30-0346-S X_ACCUMED,10096301,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,591.00,177.30,229.31,502.35,,,,,,,,,,,,,,,,,,,,229.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,443.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,295.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.35,,,percent of total billed charges,,,265.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK HEXALOBE 2.7X14MM X_30-0346-S X_ACCUMED,10096301,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,591.00,177.30,251.17,502.35,,,,,,,,,,,,,service not payable,,,,,,,298.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,251.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,443.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,295.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,443.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,502.35,,,percent of total billed charges,,,271.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X8MM,10096302,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X8MM,10096302,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X12MM,10096303,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X12MM,10096303,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X15MM,10096304,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X15MM,10096304,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X18MM,10096305,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X18MM,10096305,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X22MM,10096306,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X22MM,10096306,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X26MM,10096307,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X26MM,10096307,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X30MM,10096308,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X30MM,10096308,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X34MM,10096309,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X34MM,10096309,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.25X38MM,10096310,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.25X38MM,10096310,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X08MM,10096311,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X08MM,10096311,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X12MM,10096312,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X12MM,10096312,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X15MM,10096313,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X15MM,10096313,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X18MM,10096314,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X18MM,10096314,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X22MM,10096315,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X22MM,10096315,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X26MM,10096316,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X26MM,10096316,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X30MM,10096317,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X30MM,10096317,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X34MM,10096318,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X34MM,10096318,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.5X38MM,10096319,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.5X38MM,10096319,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X08MM,10096320,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X08MM,10096320,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X12MM,10096321,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X12MM,10096321,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X15MM,10096322,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X15MM,10096322,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X18MM,10096323,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X18MM,10096323,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X22MM,10096324,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X22MM,10096324,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X26MM,10096325,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X26MM,10096325,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X30MM,10096326,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X30MM,10096326,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X34MM,10096327,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X34MM,10096327,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.75X38MM,10096328,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.75X38MM,10096328,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X08MM,10096329,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X08MM,10096329,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X12MM,10096330,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X12MM,10096330,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X15MM,10096331,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X15MM,10096331,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X18MM,10096332,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X18MM,10096332,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X22MM,10096333,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X22MM,10096333,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X26MM,10096334,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X26MM,10096334,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X30MM,10096335,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X30MM,10096335,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X34MM,10096336,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X34MM,10096336,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.0X38MM,10096337,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.0X38MM,10096337,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X08MM,10096338,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X08MM,10096338,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X12MM,10096339,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X12MM,10096339,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X15MM,10096340,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X15MM,10096340,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X18MM,10096341,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X18MM,10096341,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X22MM,10096342,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X22MM,10096342,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X26MM,10096343,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X26MM,10096343,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X30MM,10096344,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X30MM,10096344,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X34MM,10096345,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X34MM,10096345,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 3.5X38MM,10096346,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 3.5X38MM,10096346,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X08MM,10096347,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X08MM,10096347,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X12MM,10096348,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X12MM,10096348,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X15MM,10096349,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X15MM,10096349,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X18MM,10096350,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X18MM,10096350,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X22MM,10096351,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X22MM,10096351,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X26MM,10096352,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X26MM,10096352,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X30MM,10096353,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X30MM,10096353,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X34MM,10096354,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X34MM,10096354,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 4.0X38MM,10096355,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 4.0X38MM,10096355,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC AORTA X_TAS X_LIFENET,10096867,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,24758.00,7427.40,9606.10,21044.30,,12131.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10398.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9606.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10522.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18568.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12379.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21044.30,,,percent of total billed charges,,,11141.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC AORTA X_TAS X_LIFENET,10096867,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,24758.00,7427.40,10398.36,21044.30,,12131.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10398.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12487.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10522.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18568.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12379.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18568.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21044.30,,,percent of total billed charges,,,11388.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7X35MM X_AR-8770-35H X_ARTHREX INC,10096869,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7X35MM X_AR-8770-35H X_ARTHREX INC,10096869,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DISTAL 16X195MM X_6276-7-116 X_STRYKER ORTHOP,10096871,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10272.00,3081.60,3985.54,8731.20,,5033.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4314.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3985.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4365.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7704.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8731.20,,,percent of total billed charges,,,4622.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DISTAL 16X195MM X_6276-7-116 X_STRYKER ORTHOP,10096871,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10272.00,3081.60,4314.24,8731.20,,5033.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4314.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5181.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4365.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7704.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7704.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8731.20,,,percent of total billed charges,,,4725.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS PMK ACCOLADE MRI DR 2LD X_9H32 X_BOSTON SCIENT,10096872,CDM,0278,RC,C1785,HCPCS,,,,,,inpatient,facility,,,13808.00,4142.40,5357.50,11736.80,,6765.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5799.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5357.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10356.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6904.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11736.80,,,percent of total billed charges,,,6213.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS PMK ACCOLADE MRI DR 2LD X_9H32 X_BOSTON SCIENT,10096872,CDM,0278,RC,C1785,HCPCS,,,,,,outpatient,facility,,,13808.00,4142.40,5799.36,11736.80,,6765.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5799.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6964.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5868.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10356.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6904.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10356.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11736.80,,,percent of total billed charges,,,6351.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ACCOLADE DR MRI,10098097,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,10162.00,3048.60,3942.86,8637.70,,4979.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4268.04,,,percent of total billed charges,,Paid in addition to inpatient services ,3942.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4318.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8637.70,,,percent of total billed charges,,,4572.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ACCOLADE DR MRI,10098097,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,10162.00,3048.60,4268.04,8637.70,,4979.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4268.04,,,percent of total billed charges,,Paid in addition to outpatient services ,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4318.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PERFORMA ULTIMATE 4T 45 6F X_6100381ULT4-T45,10098100,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,112.00,33.60,47.60,95.20,,69.22,,,percent of total billed charges,,,,,,,,service not payable,54.66,,,percent of total billed charges,,,56.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,47.60,,,percent of total billed charges,,,,,,,,,84.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,56.0,,,percent of total billed charges,,,,,,,,service not payable,84.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,,51.52,,,percent of total billed charges,,,,,,,,,72.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,72.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER SPG SFT 6F 11CM X_PHR6F11021SC X,10098101,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER SPG SFT 5F 11CM X_PHR5F11021SC X,10098102,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER NT STA 5F 11CM X_PHR5F11021PW X_,10098103,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN MINI 18X2.5MM,10098105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN MINI 18X2.5MM,10098105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB CLARIA MRI QUAD CRT DF4,10098249,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,55830.00,16749.00,21662.04,47455.5,,27356.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23448.60,,,percent of total billed charges,,Paid in addition to inpatient services ,21662.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23727.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,41872.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27915.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47455.5,,,percent of total billed charges,,,25123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB CLARIA MRI QUAD CRT DF4,10098249,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,55830.00,16749.00,23448.60,47455.5,,27356.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23448.60,,,percent of total billed charges,,Paid in addition to outpatient services ,28160.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,23727.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,41872.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,27915.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,41872.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,47455.5,,,percent of total billed charges,,,25681.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF TI 10X14X40MM,10098250,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13113.00,3933.90,5087.84,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5087.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,,5900.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF TI 10X14X40MM,10098250,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5507.46,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATCH DURAL DURA-GUARD 6X8CM X_DG-0608SN X_BAXTER,10098251,CDM,0623,RC,A6250,HCPCS,,,,,,outpatient,facility,,,2329.00,698.70,989.83,1979.65,,1439.32,,,percent of total billed charges,,,,,,,,service not payable,1136.55,,,percent of total billed charges,,,1174.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,989.83,,,percent of total billed charges,,,,,,,,,1746.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,,,,,,service not payable,1746.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1979.65,,,percent of total billed charges,,,1071.34,,,percent of total billed charges,,,,,,,,,1513.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1513.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SS 32THD 7.0X95MM X_7112-8095 X_SMITH N,10098253,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SS 32THD 7.0X95MM X_7112-8095 X_SMITH N,10098253,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VARIAX STRT 6H,10098356,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1915.00,574.50,743.02,1627.75,,,,,,,,,,,,,,,,,,,,743.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1436.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,957.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1627.75,,,percent of total billed charges,,,861.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VARIAX STRT 6H,10098356,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1915.00,574.50,813.88,1627.75,,,,,,,,,,,,,service not payable,,,,,,,965.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1436.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,957.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1436.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1627.75,,,percent of total billed charges,,,880.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OLEC STND 11H RT X_70-0309 X_ACUMED,10098357,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3508.00,1052.40,1361.10,2981.80,,,,,,,,,,,,,,,,,,,,1361.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1754.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.80,,,percent of total billed charges,,,1578.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OLEC STND 11H RT X_70-0309 X_ACUMED,10098357,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3508.00,1052.40,1490.90,2981.80,,,,,,,,,,,,,service not payable,,,,,,,1769.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1490.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2631.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1754.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2981.80,,,percent of total billed charges,,,1613.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1/3 TUBULAR 8H L95MM,10100240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2382.00,714.60,924.22,2024.7,,,,,,,,,,,,,,,,,,,,924.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1012.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1786.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1191.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2024.7,,,percent of total billed charges,,,1071.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1/3 TUBULAR 8H L95MM,10100240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2382.00,714.60,1012.35,2024.7,,,,,,,,,,,,,service not payable,,,,,,,1201.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1012.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1786.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1191.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1786.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2024.7,,,percent of total billed charges,,,1095.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5X8MM X_657308 X_STRYKER,10100241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X8MM X_657308 X_STRYKER,10100241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T10 FT 3.5X10MM,10100242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T10 FT 3.5X10MM,10100242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON LK T10 FT 3.5X28MM,10100243,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LK T10 FT 3.5X28MM,10100243,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE FIBULA SEG 10.1-15.9CM X_16517015 X_ALL,10100244,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2640.00,792.00,1024.32,2244.0,,,,,,,,,,,,,,,,,,,,1024.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1122.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1980.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1320.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2244.0,,,percent of total billed charges,,,1188.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE FIBULA SEG 10.1-15.9CM X_16517015 X_ALL,10100244,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2640.00,792.00,1122.0,2244.0,,,,,,,,,,,,,service not payable,,,,,,,1331.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1122.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1980.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1320.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1980.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2244.0,,,percent of total billed charges,,,1214.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CANN 4X24MM X_AR-8740-24PTS X_ARTHREX INC,10100245,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CANN 4X24MM X_AR-8740-24PTS X_ARTHREX INC,10100245,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEXALOBE 3.0X30MM X_30-0289 X_FUSION MEDI,10100247,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEXALOBE 3.0X30MM X_30-0289 X_FUSION MEDI,10100247,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT LI 11X9X26MM 0DEG X_6641926 X_NUVASIVE,10100249,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10491.00,3147.30,4070.51,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4070.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8917.35,,,percent of total billed charges,,,4720.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT LI 11X9X26MM 0DEG X_6641926 X_NUVASIVE,10100249,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10491.00,3147.30,4406.22,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5291.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8917.35,,,percent of total billed charges,,,4825.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT LI 13X9X26MM 0DEG X_6643926 X_NUVASIVE,10100250,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10491.00,3147.30,4070.51,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4070.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8917.35,,,percent of total billed charges,,,4720.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT LI 13X9X26MM 0DEG X_6643926 X_NUVASIVE,10100250,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10491.00,3147.30,4406.22,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5291.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8917.35,,,percent of total billed charges,,,4825.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT LI 7X9X26MM 0DEG X_6647926 X_NUVASIVE,10100251,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10491.00,3147.30,4070.51,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4070.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8917.35,,,percent of total billed charges,,,4720.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT LI 7X9X26MM 0DEG X_6647926 X_NUVASIVE,10100251,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10491.00,3147.30,4406.22,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5291.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8917.35,,,percent of total billed charges,,,4825.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT LI 9X9X26MM 0DEG X_6649926 X_NUVASIVE,10100252,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10491.00,3147.30,4070.51,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4070.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8917.35,,,percent of total billed charges,,,4720.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT LI 9X9X26MM 0DEG X_6649926 X_NUVASIVE,10100252,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10491.00,3147.30,4406.22,8917.35,,5140.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4406.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5291.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4458.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8917.35,,,percent of total billed charges,,,4825.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT XLR 14X34X24MM 8DEG X_6921444 X_NUVASIVE,10100253,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT XLR 14X34X24MM 8DEG X_6921444 X_NUVASIVE,10100253,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONV PREBENT 65MM X_8052065 X_NUVASIVE,10100254,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONV PREBENT 65MM X_8052065 X_NUVASIVE,10100254,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONV PREBENT 110MM X_8052110 X_NUVASIVE,10100255,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONV PREBENT 110MM X_8052110 X_NUVASIVE,10100255,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD COCR STR 45MM X_8252045 X_NUVASIVE,10100256,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD COCR STR 45MM X_8252045 X_NUVASIVE,10100256,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD COCR STR 75MM X_8252075 X_NUVASIVE,10100257,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD COCR STR 75MM X_8252075 X_NUVASIVE,10100257,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD ARMADA 75MM X_8452075 X_NUVASIVE,10100258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD ARMADA 75MM X_8452075 X_NUVASIVE,10100258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ARMADA POLY 4.5X35MM X_8454535 X_NUVASIVE,10100259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ARMADA POLY 4.5X35MM X_8454535 X_NUVASIVE,10100259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ARMADA POLY 8.5X80MM X_8458580 X_NUVASIVE,10100260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ARMADA POLY 8.5X80MM X_8458580 X_NUVASIVE,10100260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 5.5X35MM X_482315535 X_STRYKER SPINE,10100261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 5.5X35MM X_482315535 X_STRYKER SPINE,10100261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 5.5X50MM,10100262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 5.5X50MM,10100262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Screw Spine Xia 3 Titanium Polyaxial NL Buttress T,10100263,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Screw Spine Xia 3 Titanium Polyaxial NL Buttress T,10100263,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 7.5X55MM,10100264,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 7.5X55MM,10100264,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POST RAD 5.5X120MM X_486613020 X_STRYKER,10100265,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POST RAD 5.5X120MM X_486613020 X_STRYKER,10100265,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POST RAD 5.5X60MM X_486613060 X_STRYKER,10100266,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POST RAD 5.5X60MM X_486613060 X_STRYKER,10100266,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD POST RAD HEX 5.5X160MM X_486613160 X_STRYKER S,10100267,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD POST RAD HEX 5.5X160MM X_486613160 X_STRYKER S,10100267,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POST RADIUS 5.5X50MM,10100268,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POST RADIUS 5.5X50MM,10100268,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POST RADIUS 5.5X80MM,10100269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POST RADIUS 5.5X80MM,10100269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POST RADIUS 5.5X90MM,10100270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POST RADIUS 5.5X90MM,10100270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 1 LEVEL SZ20 X_48811120 X_STRYKER SP,10100271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 1 LEVEL SZ20 X_48811120 X_STRYKER SP,10100271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 1 LEVEL SZ22 X_48811122 X_STRYKER SP,10100272,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 1 LEVEL SZ22 X_48811122 X_STRYKER SP,10100272,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 2 LEVEL SZ34 X_48811234 X_STRYKER SP,10100273,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 2 LEVEL SZ34 X_48811234 X_STRYKER SP,10100273,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 2 LEVEL SZ37 X_48811237 X_STRYKER SP,10100274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 2 LEVEL SZ37 X_48811237 X_STRYKER SP,10100274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 2 LEVEL SZ40 X_48811240 X_STRYKER SP,10100275,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 2 LEVEL SZ40 X_48811240 X_STRYKER SP,10100275,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 3 LEVEL SZ45 X_48811345 X_STRYKER SP,10100276,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 3 LEVEL SZ45 X_48811345 X_STRYKER SP,10100276,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SRV FEE 8MM PLIF SPACER X_85008 X_STRYKER SPINE,10100277,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SRV FEE 8MM PLIF SPACER X_85008 X_STRYKER SPINE,10100277,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SRV FEE 10MM PLIF SPACER X_85010 X_STRYKER SPINE,10100278,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SRV FEE 10MM PLIF SPACER X_85010 X_STRYKER SPINE,10100278,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA POLY 4.5 8.5X40 X_48148540 X_STRYKER SPI,10100279,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA POLY 4.5 8.5X40 X_48148540 X_STRYKER SPI,10100279,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA POLY 4.5 8.5X45 X_48148545 X_STRYKER SPI,10100280,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA POLY 4.5 8.5X45 X_48148545 X_STRYKER SPI,10100280,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA POLY 4.5 8.5X90 X_48148590 X_STRYKER SPI,10100281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA POLY 4.5 8.5X90 X_48148590 X_STRYKER SPI,10100281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE AVIATOR LVL 3 SZ48,10100282,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE AVIATOR LVL 3 SZ48,10100282,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR LVL 3 SZ51 X_48811351 X_STRYKER SPIN,10100283,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR LVL 3 SZ51 X_48811351 X_STRYKER SPIN,10100283,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR LVL 3 SZ54 X_48811354 X_STRYKER SPIN,10100284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR LVL 3 SZ54 X_48811354 X_STRYKER SPIN,10100284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARIABLE ANG 4X16MM X_48814016 X_STRYKER SPI,10100285,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARIABLE ANG 4X16MM X_48814016 X_STRYKER SPI,10100285,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARIABLE ANG 4.35X12MM X_48814512 X_STRYKER,10100286,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARIABLE ANG 4.35X12MM X_48814512 X_STRYKER,10100286,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VAR ANG 4.35X14MM,10100287,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VAR ANG 4.35X14MM,10100287,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARIABLE ANG 4.0X14MM X_48834014 X_STRYKER S,10100288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARIABLE ANG 4.0X14MM X_48834014 X_STRYKER S,10100288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FIXED ANG 4.35X20MM X_48834520 X_STRYKER SPI,10100289,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FIXED ANG 4.35X20MM X_48834520 X_STRYKER SPI,10100289,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV SPINE 4DEG 5MM,10100290,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV SPINE 4DEG 5MM,10100290,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV SPINE 4DEG 6MM,10100291,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV SPINE 4DEG 6MM,10100291,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV SPINE 4DEG 7MM,10100292,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV SPINE 4DEG 7MM,10100292,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV SPINE ALLOG 4DEG 8MM,10100293,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV SPINE ALLOG 4DEG 8MM,10100293,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 3 TI 6X60MM X_48233060 X_STRYKER SPINE,10100294,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 3 TI 6X60MM X_48233060 X_STRYKER SPINE,10100294,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 CLOSED HEAD X_48233500 X_STRYKER SPINE,10100295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 CLOSED HEAD X_48233500 X_STRYKER SPINE,10100295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CROSSLINK XIA 3 TI MULTI X_48236070 X_STRYKER SPIN,10100296,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CROSSLINK XIA 3 TI MULTI X_48236070 X_STRYKER SPIN,10100296,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 8X30MM 4D X_48370084 X_STRYKER SPI,10100297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 8X30MM 4D X_48370084 X_STRYKER SPI,10100297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 10X30MM 0D X_48370100 X_STRYKER SP,10100298,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 10X30MM 0D X_48370100 X_STRYKER SP,10100298,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 4D 11X30MM,10100299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 11X30MM,10100299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 12X30MM 0D X_48370120 X_STRYKER SP,10100300,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 12X30MM 0D X_48370120 X_STRYKER SP,10100300,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 4D 12X30MM,10100301,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 12X30MM,10100301,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 13X30MM 0D X_48370130 X_STRYKER SP,10100302,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 13X30MM 0D X_48370130 X_STRYKER SP,10100302,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 6X12X14MM 0D X_48322060 X_STRYKER,10100303,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 6X12X14MM 0D X_48322060 X_STRYKER,10100303,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 7X12X14MM 0D X_48322070 X_STRYKER,10100304,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 7X12X14MM 0D X_48322070 X_STRYKER,10100304,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 7X12X14MM 4D X_48322074 X_STRYKER,10100305,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 7X12X14MM 4D X_48322074 X_STRYKER,10100305,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 8X12X14MM 0D X_48322080 X_STRYKER,10100306,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 8X12X14MM 0D X_48322080 X_STRYKER,10100306,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVSPL 7X11X30MM 4D X_48351074 X_STRYKE,10100307,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVSPL 7X11X30MM 4D X_48351074 X_STRYKE,10100307,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVSPL 8X11X30MM 4D X_48351084 X_STRYKE,10100308,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVSPL 8X11X30MM 4D X_48351084 X_STRYKE,10100308,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 4D 7X25MM,10100309,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 7X25MM,10100309,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 4D 9X25MM,10100310,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 9X25MM,10100310,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 11X25MM 0D X_48375110 X_STRYKER SP,10100311,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 11X25MM 0D X_48375110 X_STRYKER SP,10100311,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 11X25MM 4D X_48375114 X_STRYKER SP,10100312,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 11X25MM 4D X_48375114 X_STRYKER SP,10100312,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 4D 12X25MM,10100313,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 12X25MM,10100313,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 13X25MM 4D X_48375134 X_STRYKER SP,10100314,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 13X25MM 4D X_48375134 X_STRYKER SP,10100314,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 11X12X25MM X_48395120 X_STRYKER SP,10100315,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 11X12X25MM X_48395120 X_STRYKER SP,10100315,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SPINE POST 3.5MM X_48551070 X_STRYKER SP,10100316,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SPINE POST 3.5MM X_48551070 X_STRYKER SP,10100316,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD THORASIC POST 400X3.5MM,10100317,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD THORASIC POST 400X3.5MM,10100317,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLYAXIAL 12X3.5MM,10100318,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLYAXIAL 12X3.5MM,10100318,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SPINE 3 LEVEL SZ51 X_48651351 X_STRYKER SPIN,10100319,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SPINE 3 LEVEL SZ51 X_48651351 X_STRYKER SPIN,10100319,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PFL-Six Minute Walk,10100390,CDM,0460,RC,94618,CPT,,,,,,outpatient,facility,,,328.00,98.40,139.40,983.0,,202.70,,,percent of total billed charges,,,,,,,,,160.06,,,percent of total billed charges,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PFL-Six Minute Walk,10100390,CDM,0460,RC,94618,CPT,05734,APC,,,,outpatient,facility,,,328.00,98.40,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
PFL-Six Minute Walk,10100390,CDM,0460,RC,94618,CPT,412,EAPG,,,,outpatient,facility,,,328.00,98.40,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CRTX ST 1.3X12MM,10102677,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,273.00,81.90,105.92,232.05,,,,,,,,,,,,,,,,,,,,105.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,,122.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST 1.3X12MM,10102677,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,273.00,81.90,116.02,232.05,,,,,,,,,,,,,service not payable,,,,,,,137.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,204.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,204.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,125.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONN CARBN 5X250 X_5049-5-525 X_STRYKER ORTHOP,10102679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,364.00,109.20,141.23,309.40,,,,,,,,,,,,,,,,,,,,141.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,273.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,182.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,309.40,,,percent of total billed charges,,,163.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONN CARBN 5X250 X_5049-5-525 X_STRYKER ORTHOP,10102679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,364.00,109.20,154.70,309.40,,,,,,,,,,,,,service not payable,,,,,,,183.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,154.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,182.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,273.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,309.40,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COUPLING PIN-ROD 3X4MM COMPACT,10102680,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1577.00,473.10,611.88,1340.45,,,,,,,,,,,,,,,,,,,,611.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,670.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1182.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,788.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1340.45,,,percent of total billed charges,,,709.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COUPLING PIN-ROD 3X4MM COMPACT,10102680,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1577.00,473.10,670.23,1340.45,,,,,,,,,,,,,service not payable,,,,,,,795.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,670.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1182.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,788.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1182.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1340.45,,,percent of total billed charges,,,725.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP OMEGA 32.3MM X_596001S X_STRYKER ORTHOP,10102681,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,358.00,107.40,138.90,304.30,,,,,,,,,,,,,,,,,,,,138.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,268.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,,161.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP OMEGA 32.3MM X_596001S X_STRYKER ORTHOP,10102681,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,358.00,107.40,152.15,304.30,,,,,,,,,,,,,service not payable,,,,,,,180.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,152.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,268.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,179.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,268.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,,164.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIAT ANT CERV 4H 18MM X_48811118 X_STRYKER,10102682,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIAT ANT CERV 4H 18MM X_48811118 X_STRYKER,10102682,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FXD AVIAT ST 4X16MM X_48834016 X_STRYKER SPI,10102683,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FXD AVIAT ST 4X16MM X_48834016 X_STRYKER SPI,10102683,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VAR LK ANG 2.3X18MM,10102684,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,689.00,206.70,267.33,585.65,,,,,,,,,,,,,,,,,,,,267.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.65,,,percent of total billed charges,,,310.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VAR LK ANG 2.3X18MM,10102684,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,689.00,206.70,292.82,585.65,,,,,,,,,,,,,service not payable,,,,,,,347.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,516.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,585.65,,,percent of total billed charges,,,316.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INTRATHECAL 4.0FR 73.7CM,10102688,CDM,0272,RC,C1755,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,1350.95,,,percent of total billed charges,,,,,,,,service not payable,1066.77,,,percent of total billed charges,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,1420.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1420.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCK 26HOLE ANG R X_25-775-26-09 X_KLS MARTIN,10102694,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4182.00,1254.60,1622.62,3554.70,,,,,,,,,,,,,,,,,,,,1622.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1777.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3136.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3554.70,,,percent of total billed charges,,,1881.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCK 26HOLE ANG R X_25-775-26-09 X_KLS MARTIN,10102694,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4182.00,1254.60,1777.35,3554.70,,,,,,,,,,,,,service not payable,,,,,,,2109.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1777.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3136.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3136.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3554.70,,,percent of total billed charges,,,1923.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD POLARIS CVD TI 5.5 X 110MM,10102696,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD POLARIS CVD TI 5.5 X 110MM,10102696,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 9X14X34 X_5294348 X_NUVASIVE,10102697,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13113.00,3933.90,5087.84,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5087.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,,5900.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 9X14X34 X_5294348 X_NUVASIVE,10102697,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5507.46,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB SIGMA CVD SZ4 10MM,10102698,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB SIGMA CVD SZ4 10MM,10102698,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT MESH BIODESIGN 7X20CM,10102700,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,4180.00,1254.00,1621.84,3553.0,,,,,,,,,,,,,,,,,,,,1621.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1776.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,,1881.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT MESH BIODESIGN 7X20CM,10102700,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,4180.00,1254.00,1776.5,3553.0,,,,,,,,,,,,,service not payable,,,,,,,2108.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1776.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,,1922.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT CONNECTION 20MM X_103203 X_SMITH NEPHEW,10102701,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,42.00,12.60,16.30,35.70,,,,,,,,,,,,,,,,,,,,16.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,31.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.70,,,percent of total billed charges,,,18.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT CONNECTION 20MM X_103203 X_SMITH NEPHEW,10102701,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,42.00,12.60,17.85,35.70,,,,,,,,,,,,,service not payable,,,,,,,21.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,31.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,31.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,35.70,,,percent of total billed charges,,,19.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT CANN LONG WIRE 8MM,10102702,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT CANN LONG WIRE 8MM,10102702,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB OPEN WEDGE 10MM X_AR-13200-10.0 X_ARTHRE,10102703,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB OPEN WEDGE 10MM X_AR-13200-10.0 X_ARTHRE,10102703,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOW PROF TI 4.5MMX55MM,10102704,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOW PROF TI 4.5MMX55MM,10102704,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCK 2.7X34MM X_7182-3034 X_SMITH NEPHEW,10102705,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,108.00,32.40,41.90,91.80,,,,,,,,,,,,,,,,,,,,41.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,81.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.80,,,percent of total billed charges,,,48.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCK 2.7X34MM X_7182-3034 X_SMITH NEPHEW,10102705,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,108.00,32.40,45.90,91.80,,,,,,,,,,,,,service not payable,,,,,,,54.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,45.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,81.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,54.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,81.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,91.80,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD MAC 38-43MM X_4107038 X_STRYKER SPINE,10102706,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD MAC 38-43MM X_4107038 X_STRYKER SPINE,10102706,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD MAC 42-51MM X_4107042 X_STRYKER SPINE,10102707,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD MAC 42-51MM X_4107042 X_STRYKER SPINE,10102707,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 3 TI CP 6X110MM X_48232110 X_STRYKER SPINE,10102709,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 3 TI CP 6X110MM X_48232110 X_STRYKER SPINE,10102709,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 3 TI CP 6X600MM X_48232600 X_STRYKER SPINE,10102710,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 3 TI CP 6X600MM X_48232600 X_STRYKER SPINE,10102710,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 3 TI 6X40MM X_48233040 X_STRYKER SPINE,10102711,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 3 TI 6X40MM X_48233040 X_STRYKER SPINE,10102711,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PLUG CERV 0D 8MM X_77102080 X_STRYKER S,10102712,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6252.00,1875.60,2425.78,5314.20,,3063.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2625.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2425.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2657.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4689.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5314.20,,,percent of total billed charges,,,2813.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PLUG CERV 0D 8MM X_77102080 X_STRYKER S,10102712,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6252.00,1875.60,2625.84,5314.20,,3063.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2625.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3153.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2657.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4689.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3126.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4689.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5314.20,,,percent of total billed charges,,,2875.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE 12X10MM X_336612010 X_STRYKER SPINE,10102713,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE 12X10MM X_336612010 X_STRYKER SPINE,10102713,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE 12X40MM X_336612040 X_STRYKER SPINE,10102714,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,14445.00,4333.50,5604.66,12278.25,,7078.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6066.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5604.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6139.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10833.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7222.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12278.25,,,percent of total billed charges,,,6500.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE 12X40MM X_336612040 X_STRYKER SPINE,10102714,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,14445.00,4333.50,6066.90,12278.25,,7078.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6066.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7286.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6139.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10833.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7222.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10833.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12278.25,,,percent of total billed charges,,,6644.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE 14X40MM X_336614040 X_STRYKER SPINE,10102715,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE 14X40MM X_336614040 X_STRYKER SPINE,10102715,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUT PASSER KNEE MINISCAL SCORP,10102716,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUT PASSER KNEE MINISCAL SCORP,10102716,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 5.5X35MM X_482305535 X_STRYKER S,10102718,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 5.5X35MM X_482305535 X_STRYKER S,10102718,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 5.5X40MM X_482305540 X_STRYKER S,10102719,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 5.5X40MM X_482305540 X_STRYKER S,10102719,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 5.5X45MM X_482305545 X_STRYKER S,10102720,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 5.5X45MM X_482305545 X_STRYKER S,10102720,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 6.5X40MM X_482306540 X_STRYKER S,10102721,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 6.5X40MM X_482306540 X_STRYKER S,10102721,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 6.5X45MM X_482306545 X_STRYKER S,10102722,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 6.5X45MM X_482306545 X_STRYKER S,10102722,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 6.5X55MM X_482306555 X_STRYKER S,10102723,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 6.5X55MM X_482306555 X_STRYKER S,10102723,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 TI MA 7.5X50MM X_482307550 X_STRYKER S,10102724,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 TI MA 7.5X50MM X_482307550 X_STRYKER S,10102724,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 11PL 0D 15X25MM X_483515150 X_STRYKER,10102725,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 11PL 0D 15X25MM X_483515150 X_STRYKER,10102725,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEXALOBE 2.7X10MM X_30-0325-S X_ACUMED,10102726,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,842.00,252.60,326.70,715.70,,,,,,,,,,,,,,,,,,,,326.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.70,,,percent of total billed charges,,,378.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEXALOBE 2.7X10MM X_30-0325-S X_ACUMED,10102726,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,842.00,252.60,357.85,715.70,,,,,,,,,,,,,service not payable,,,,,,,424.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,631.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,715.70,,,percent of total billed charges,,,387.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE PIN GREAT TOE 2X125MM X_GDW89000 X_INTEGRA L,10102729,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,363.00,108.90,140.84,308.55,,,,,,,,,,,,,,,,,,,,140.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.55,,,percent of total billed charges,,,163.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE PIN GREAT TOE 2X125MM X_GDW89000 X_INTEGRA L,10102729,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,363.00,108.90,154.28,308.55,,,,,,,,,,,,,service not payable,,,,,,,183.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,154.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,272.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,272.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,308.55,,,percent of total billed charges,,,166.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS CLARIA MRI QUAD CRT D MMQM X_CLARIAMRIQDCRTMMQ,10102730,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,47258.00,14177.40,18336.10,40169.30,,23156.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19848.36,,,percent of total billed charges,,Paid in addition to inpatient services ,18336.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20084.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,35443.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40169.30,,,percent of total billed charges,,,21266.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS CLARIA MRI QUAD CRT D MMQM X_CLARIAMRIQDCRTMMQ,10102730,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,47258.00,14177.40,19848.36,40169.30,,23156.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19848.36,,,percent of total billed charges,,Paid in addition to outpatient services ,23836.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,20084.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,35443.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,23629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,35443.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,40169.30,,,percent of total billed charges,,,21738.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 7FR 7CM X_8893 X_VASCULAR SOLUTI,10102732,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,91.46,,,percent of total billed charges,,,,,,,,service not payable,72.22,,,percent of total billed charges,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,96.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,96.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH MICRO ACCESS 7FR 11CM X_8984 X_VASCULAR SOL,10102734,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,91.46,,,percent of total billed charges,,,,,,,,service not payable,72.22,,,percent of total billed charges,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,96.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,96.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CLOSUREFAST 7FRX60CM,10102735,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,1097.57,,,percent of total billed charges,,,,,,,,service not payable,866.69,,,percent of total billed charges,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,1154.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1154.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CLOSUREFAST 7FRX100CM,10102736,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,1097.57,,,percent of total billed charges,,,,,,,,service not payable,866.69,,,percent of total billed charges,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,1154.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1154.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE DBL END .025 150CM,10102738,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,112.00,33.60,47.60,95.20,,69.22,,,percent of total billed charges,,,,,,,,service not payable,54.66,,,percent of total billed charges,,,56.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,47.60,,,percent of total billed charges,,,,,,,,,84.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,56.0,,,percent of total billed charges,,,,,,,,service not payable,84.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,,51.52,,,percent of total billed charges,,,,,,,,,72.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,72.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Puncture aspiration of breast cyst,10103318,CDM,0450,RC,19000,CPT,,,,,,outpatient,facility,,,1422.00,426.60,654.12,1208.7,,878.80,,,percent of total billed charges,,,,,,,,,693.94,,,percent of total billed charges,,,717.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1066.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1066.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1208.7,,,percent of total billed charges,,,654.12,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Puncture aspiration of breast cyst,10103318,CDM,0450,RC,19000,CPT,05071,APC,,,,outpatient,facility,,,1422.00,426.60,323.59,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,323.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,323.59,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,323.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Puncture aspiration of breast cyst,10103318,CDM,0450,RC,19000,CPT,2,EAPG,,,,outpatient,facility,,,1422.00,426.60,933.72,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR/SPL,10103324,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR/SPL,10103324,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR/SPL,10103324,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR,10103325,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1164.00,349.20,180.0,989.40,,719.35,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,587.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.70,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.40,,,percent of total billed charges,,,535.44,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR,10103325,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1164.00,349.20,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR,10103325,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1164.00,349.20,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR,10103326,CDM,0390,RC,P9035,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR,10103326,CDM,0390,RC,P9035,HCPCS,09501,APC,,,,outpatient,facility,,,1070.00,321.00,448.05,1100.85,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,1008.3,,,fee schedule,,,448.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",488.90,,,fee schedule,,,1100.85,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,993.68,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,448.05,,,fee schedule,,,488.90,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,448.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",488.90,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,484.08,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR,10103326,CDM,0390,RC,P9035,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR P3,10103327,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,180.0,1045.5,,760.14,,,percent of total billed charges,,,,,,,,,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR P3,10103327,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1230.00,369.00,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR P3,10103327,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1230.00,369.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR P3/SPL,10103328,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR P3/SPL,10103328,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR P3/SPL,10103328,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR P2,10103329,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,180.0,1045.5,,760.14,,,percent of total billed charges,,,,,,,,,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR P2,10103329,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1230.00,369.00,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR P2,10103329,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1230.00,369.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR P2/SPL,10103330,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR P2/SPL,10103330,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR P2/SPL,10103330,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR P2,10103331,CDM,0390,RC,P9035,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR P2,10103331,CDM,0390,RC,P9035,HCPCS,09501,APC,,,,outpatient,facility,,,1070.00,321.00,448.05,1100.85,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,1008.3,,,fee schedule,,,448.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",488.90,,,fee schedule,,,1100.85,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,993.68,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,448.05,,,fee schedule,,,488.90,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,448.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",488.90,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,484.08,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR P2,10103331,CDM,0390,RC,P9035,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR P2/SPL,10103332,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR P2/SPL,10103332,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR P2/SPL,10103332,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR/SPL,10103333,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR/SPL,10103333,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR/SPL,10103333,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR P1,10103334,CDM,0390,RC,P9035,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR P1,10103334,CDM,0390,RC,P9035,HCPCS,09501,APC,,,,outpatient,facility,,,1070.00,321.00,448.05,1100.85,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,1008.3,,,fee schedule,,,448.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",488.90,,,fee schedule,,,1100.85,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,993.68,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,448.05,,,fee schedule,,,488.90,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,448.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",488.90,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,484.08,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR P1,10103334,CDM,0390,RC,P9035,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR P1/SPL,10103335,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR P1/SPL,10103335,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR P1/SPL,10103335,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC VC LR,10103336,CDM,0390,RC,P9035,HCPCS,,,,,,outpatient,facility,,,1136.00,340.80,180.0,965.60,,702.05,,,percent of total billed charges,,,,,,,,,554.37,,,percent of total billed charges,,,573.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.80,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.0,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,965.60,,,percent of total billed charges,,,522.56,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC VC LR,10103336,CDM,0390,RC,P9035,HCPCS,09501,APC,,,,outpatient,facility,,,1136.00,340.80,448.05,1100.85,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,1008.3,,,fee schedule,,,448.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",488.90,,,fee schedule,,,1100.85,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,993.68,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,448.05,,,fee schedule,,,488.90,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,448.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",488.90,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,484.08,,,fee schedule,,,,,,,,
PltPh ACDA PASC VC LR,10103336,CDM,0390,RC,P9035,HCPCS,2062,EAPG,,,,outpatient,facility,,,1136.00,340.80,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC VC LR IR,10103337,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,180.0,1045.5,,760.14,,,percent of total billed charges,,,,,,,,,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC VC LR IR,10103337,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1230.00,369.00,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC VC LR IR,10103337,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1230.00,369.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR P3,10103338,CDM,0390,RC,P9035,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR P3,10103338,CDM,0390,RC,P9035,HCPCS,09501,APC,,,,outpatient,facility,,,1070.00,321.00,448.05,1100.85,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,1008.3,,,fee schedule,,,448.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",488.90,,,fee schedule,,,1100.85,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,993.68,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,448.05,,,fee schedule,,,488.90,,,fee schedule,,,,,,,,,479.31,,,fee schedule,,,,,,,,,448.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",488.90,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,,,,,,,479.31,,,fee schedule,,,,,,,,,484.08,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR P3,10103338,CDM,0390,RC,P9035,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC VC LR IR/SPL,10103339,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC VC LR IR/SPL,10103339,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC VC LR IR/SPL,10103339,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR P3/SPL,10103340,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR P3/SPL,10103340,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR P3/SPL,10103340,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC VC LR/SPL,10103341,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC VC LR/SPL,10103341,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC VC LR/SPL,10103341,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR P3/SPL,10103342,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR P3/SPL,10103342,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR P3/SPL,10103342,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR P3,10103343,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1164.00,349.20,180.0,989.40,,719.35,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,587.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.70,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.40,,,percent of total billed charges,,,535.44,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR P3,10103343,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1164.00,349.20,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR P3,10103343,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1164.00,349.20,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR P2/SPL,10103344,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR P2/SPL,10103344,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR P2/SPL,10103344,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR P2,10103345,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1164.00,349.20,180.0,989.40,,719.35,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,587.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.70,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.40,,,percent of total billed charges,,,535.44,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR P2,10103345,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1164.00,349.20,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR P2,10103345,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1164.00,349.20,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR P1,10103346,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,180.0,1045.5,,760.14,,,percent of total billed charges,,,,,,,,,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR P1,10103346,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1230.00,369.00,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR P1,10103346,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1230.00,369.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR P1/SPL,10103347,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR P1/SPL,10103347,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR P1/SPL,10103347,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR/SPL,10103348,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR/SPL,10103348,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR/SPL,10103348,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR VR,10103349,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,180.0,1045.5,,760.14,,,percent of total billed charges,,,,,,,,,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR VR,10103349,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1230.00,369.00,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR VR,10103349,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1230.00,369.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR P1/SPL,10103350,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR P1/SPL,10103350,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR P1/SPL,10103350,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR IR P1,10103351,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,1164.00,349.20,180.0,989.40,,719.35,,,percent of total billed charges,,,,,,,,,568.03,,,percent of total billed charges,,,587.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.70,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.40,,,percent of total billed charges,,,535.44,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR IR P1,10103351,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,1164.00,349.20,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR IR P1,10103351,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,1164.00,349.20,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR/SPL,10103362,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR/SPL,10103362,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR/SPL,10103362,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR P1,10103363,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR P1,10103363,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1070.00,321.00,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR P1,10103363,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR VR P2/SPL,10103364,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR VR P2/SPL,10103364,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR VR P2/SPL,10103364,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC VC LR PR,10103365,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC VC LR PR,10103365,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1070.00,321.00,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC VC LR PR,10103365,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC VC LR PR/SPL,10103366,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC VC LR PR/SPL,10103366,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC VC LR PR/SPL,10103366,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR VR,10103367,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1136.00,340.80,180.0,965.60,,702.05,,,percent of total billed charges,,,,,,,,,554.37,,,percent of total billed charges,,,573.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.80,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.0,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,965.60,,,percent of total billed charges,,,522.56,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR VR,10103367,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1136.00,340.80,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR VR,10103367,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1136.00,340.80,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR VR/SPL,10103368,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR VR/SPL,10103368,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR VR/SPL,10103368,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR VR P1/SPL,10103369,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR VR P1/SPL,10103369,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR VR P1/SPL,10103369,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR VR P1,10103370,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1136.00,340.80,180.0,965.60,,702.05,,,percent of total billed charges,,,,,,,,,554.37,,,percent of total billed charges,,,573.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.80,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.0,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,965.60,,,percent of total billed charges,,,522.56,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR VR P1,10103370,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1136.00,340.80,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR VR P1,10103370,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1136.00,340.80,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR VR P2,10103371,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1136.00,340.80,180.0,965.60,,702.05,,,percent of total billed charges,,,,,,,,,554.37,,,percent of total billed charges,,,573.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.80,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.0,,,percent of total billed charges,,,,,,,,,852.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,965.60,,,percent of total billed charges,,,522.56,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR VR P2,10103371,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1136.00,340.80,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR VR P2,10103371,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1136.00,340.80,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR P2,10103372,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR P2,10103372,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1070.00,321.00,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR P2,10103372,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR P1/SPL,10103373,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR P1/SPL,10103373,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR P1/SPL,10103373,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR,10103374,CDM,0390,RC,P9073,HCPCS,,,,,,outpatient,facility,,,1070.00,321.00,180.0,909.5,,661.26,,,percent of total billed charges,,,,,,,,,522.16,,,percent of total billed charges,,,539.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.0,,,percent of total billed charges,,,,,,,,,802.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.5,,,percent of total billed charges,,,492.20,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR,10103374,CDM,0390,RC,P9073,HCPCS,09536,APC,,,,outpatient,facility,,,1070.00,321.00,540.19,1327.25,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1215.67,,,fee schedule,,,540.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",589.44,,,fee schedule,,,1327.25,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,1198.05,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,540.19,,,fee schedule,,,589.44,,,fee schedule,,,,,,,,,577.88,,,fee schedule,,,,,,,,,540.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",589.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,,,,,,,577.88,,,fee schedule,,,,,,,,,583.64,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR,10103374,CDM,0390,RC,P9073,HCPCS,2062,EAPG,,,,outpatient,facility,,,1070.00,321.00,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PltPh ACDA PASC LR PR P2/SPL,10103375,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,180.0,454.75,,330.63,,,percent of total billed charges,,,,,,,,,261.08,,,percent of total billed charges,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PltPh ACDA PASC LR PR P2/SPL,10103375,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,535.00,160.50,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
PltPh ACDA PASC LR PR P2/SPL,10103375,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,535.00,160.50,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANC FT 4.0X28MM X_607328 X_STRYKER ORTHOPAE,10104122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT 4.0X28MM X_607328 X_STRYKER ORTHOPAE,10104122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VRX STRT FIB 10H 132MM X_40-20810S X_STRYKER,10104123,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2078.00,623.40,806.26,1766.3,,,,,,,,,,,,,,,,,,,,806.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,883.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1558.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1766.3,,,percent of total billed charges,,,935.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VRX STRT FIB 10H 132MM X_40-20810S X_STRYKER,10104123,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2078.00,623.40,883.15,1766.3,,,,,,,,,,,,,service not payable,,,,,,,1048.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,883.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1558.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1039.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1558.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1766.3,,,percent of total billed charges,,,955.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE BASE TI 8X38X28 10DEG X_6952810 X_NUVASIVE,10104124,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE BASE TI 8X38X28 10DEG X_6952810 X_NUVASIVE,10104124,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE BASE TI 10X38X28 15DEG X_6952015 X_NUVASIVE,10104125,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE BASE TI 10X38X28 15DEG X_6952015 X_NUVASIVE,10104125,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T8 FT 2.4X34MM X_656034 X_STRYKER ORTHO,10104126,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T8 FT 2.4X34MM X_656034 X_STRYKER ORTHO,10104126,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 4X65MM X_604665 X_STRYKER ORTHOPAEDI,10104127,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,862.00,258.60,334.46,732.70,,,,,,,,,,,,,,,,,,,,334.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,646.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,431.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.70,,,percent of total billed charges,,,387.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 4X65MM X_604665 X_STRYKER ORTHOPAEDI,10104127,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,862.00,258.60,366.35,732.70,,,,,,,,,,,,,service not payable,,,,,,,434.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,366.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,646.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,431.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,646.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,732.70,,,percent of total billed charges,,,396.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7X50MM,10104128,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7X50MM,10104128,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER INTRATHECAL X_11823 X_FLOWONIX,10106227,CDM,0272,RC,C1755,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.78,2229.55,,1621.01,,,percent of total billed charges,,,,,,,,service not payable,1280.02,,,percent of total billed charges,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.78,,,percent of total billed charges,,,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,1704.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1704.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL MIDFOOT LG 3MM X_AR-8952DFL X_ARTHREX,10106228,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL MIDFOOT LG 3MM X_AR-8952DFL X_ARTHREX,10106228,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSION CERVICAL 12X14X6 X_1000-00-0614 X_NU,10106229,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSION CERVICAL 12X14X6 X_1000-00-0614 X_NU,10106229,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Drainage of Skenes Gland Abscess or Cyst,10108214,CDM,0450,RC,53060,CPT,,,,,,outpatient,facility,,,4341.00,1302.30,774.0,3689.85,,2682.74,,,percent of total billed charges,,,,,,,,,2118.41,,,percent of total billed charges,,,2189.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3255.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3255.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3689.85,,,percent of total billed charges,,,1996.86,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Drainage of Skenes Gland Abscess or Cyst,10108214,CDM,0450,RC,53060,CPT,05373,APC,,,,outpatient,facility,,,4341.00,1302.30,942.13,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,942.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,942.13,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,942.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
Drainage of Skenes Gland Abscess or Cyst,10108214,CDM,0450,RC,53060,CPT,166,EAPG,,,,outpatient,facility,,,4341.00,1302.30,4168.12,7646.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7646.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6499.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4168.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4168.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4168.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6341.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,6975.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GWIRE GRNDSLM 180CM,10108379,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CMNT LONG LFT SZ 5 X_6088-0525-250L X_STR,10108380,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17056.00,5116.80,6617.73,14497.6,,8357.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7163.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6617.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7248.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12792.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8528.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14497.6,,,percent of total billed charges,,,7675.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CMNT LONG LFT SZ 5 X_6088-0525-250L X_STR,10108380,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17056.00,5116.80,7163.52,14497.6,,8357.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7163.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8603.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7248.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12792.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8528.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12792.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14497.6,,,percent of total billed charges,,,7845.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2H DUAL TIGRP SYNDSMS X_AR8958TDS X_ARTHREX,10108381,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2H DUAL TIGRP SYNDSMS X_AR8958TDS X_ARTHREX,10108381,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC DISTAL X_VAMF4036C150TU X_MED,10108382,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,40421.00,12126.30,15683.35,34357.85,,19806.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16976.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15683.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17178.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,30315.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20210.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34357.85,,,percent of total billed charges,,,18189.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC DISTAL X_VAMF4036C150TU X_MED,10108382,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,40421.00,12126.30,16976.82,34357.85,,19806.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16976.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,20388.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17178.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,30315.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20210.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,30315.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34357.85,,,percent of total billed charges,,,18593.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PARALLEL POST LUMBAR 11MM X_26804842 X_DCI,10108383,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8851.00,2655.30,3434.19,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3434.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.35,,,percent of total billed charges,,,3982.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PARALLEL POST LUMBAR 11MM X_26804842 X_DCI,10108383,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8851.00,2655.30,3717.42,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4464.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6638.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7523.35,,,percent of total billed charges,,,4071.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SZ13 LNTH 128MM X_5569-P-2013 X_STRYK,10108384,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8085.00,2425.50,3136.98,6872.25,,3961.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3395.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3136.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6063.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4042.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6872.25,,,percent of total billed charges,,,3638.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SZ13 LNTH 128MM X_5569-P-2013 X_STRYK,10108384,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8085.00,2425.50,3395.70,6872.25,,3961.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3395.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4078.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3436.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6063.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4042.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6063.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6872.25,,,percent of total billed charges,,,3719.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
REPAIR SYNDESMOSIS T-ROPE KL,10108385,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REPAIR SYNDESMOSIS T-ROPE KL,10108385,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR FASTFIX 360 X_72203986 X_SMITH NEPHEW,10108387,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2833.00,849.90,1099.20,2408.05,,,,,,,,,,,,,,,,,,,,1099.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1204.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2124.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1416.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2408.05,,,percent of total billed charges,,,1274.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR FASTFIX 360 X_72203986 X_SMITH NEPHEW,10108387,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2833.00,849.90,1204.02,2408.05,,,,,,,,,,,,,service not payable,,,,,,,1428.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1204.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2124.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1416.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2124.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2408.05,,,percent of total billed charges,,,1303.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRACTION IMP FIXATION 3.2MM,10108388,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRACTION IMP FIXATION 3.2MM,10108388,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK COMP HEX 35X4.75MM,10108389,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK COMP HEX 35X4.75MM,10108389,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK COMP HEX 35X6.5MM,10108390,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,437.00,131.10,169.56,371.45,,,,,,,,,,,,,,,,,,,,169.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,196.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK COMP HEX 35X6.5MM,10108390,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,,,,,,,,,,,,service not payable,,,,,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2.4MM 3HX5H X_72442454 X_SMITH NEPHEW,10108392,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2866.00,859.80,1112.01,2436.10,,,,,,,,,,,,,,,,,,,,1112.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1218.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2149.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1433.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2436.10,,,percent of total billed charges,,,1289.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2.4MM 3HX5H X_72442454 X_SMITH NEPHEW,10108392,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2866.00,859.80,1218.05,2436.10,,,,,,,,,,,,,service not payable,,,,,,,1445.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1218.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2149.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1433.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2149.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2436.10,,,percent of total billed charges,,,1318.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2.4X14MM X_72402414 X_SMITH NEPHEW,10108393,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,180.00,54.00,69.84,153.0,,,,,,,,,,,,,,,,,,,,69.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.0,,,percent of total billed charges,,,81.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2.4X14MM X_72402414 X_SMITH NEPHEW,10108393,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,180.00,54.00,76.5,153.0,,,,,,,,,,,,,service not payable,,,,,,,90.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.0,,,percent of total billed charges,,,82.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2.4X17MM X_72402417 X_SMITH NEPHEW,10108394,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,180.00,54.00,69.84,153.0,,,,,,,,,,,,,,,,,,,,69.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.0,,,percent of total billed charges,,,81.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2.4X17MM X_72402417 X_SMITH NEPHEW,10108394,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,180.00,54.00,76.5,153.0,,,,,,,,,,,,,service not payable,,,,,,,90.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.0,,,percent of total billed charges,,,82.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2.4X21MM X_72402421 X_SMITH NEPHEW,10108395,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,180.00,54.00,69.84,153.0,,,,,,,,,,,,,,,,,,,,69.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.0,,,percent of total billed charges,,,81.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2.4X21MM X_72402421 X_SMITH NEPHEW,10108395,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,180.00,54.00,76.5,153.0,,,,,,,,,,,,,service not payable,,,,,,,90.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.0,,,percent of total billed charges,,,82.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X14MM X_72412414 X_SMITH NEPHEW,10108396,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X14MM X_72412414 X_SMITH NEPHEW,10108396,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X24MM X_72412424 X_SMITH NEPHEW,10108397,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X24MM X_72412424 X_SMITH NEPHEW,10108397,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 535ML,10108398,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 535ML,10108398,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE INOGEN X4 IS1 3LD X_8FAC X_BOSTON SCIENTIFI,10108399,CDM,0275,RC,C1722,HCPCS,,,,,,inpatient,facility,,,34968.00,10490.40,13567.58,29722.80,,17134.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14686.56,,,percent of total billed charges,,Paid in addition to inpatient services ,13567.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14861.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26226.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17484.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29722.80,,,percent of total billed charges,,,15735.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE INOGEN X4 IS1 3LD X_8FAC X_BOSTON SCIENTIFI,10108399,CDM,0275,RC,C1722,HCPCS,,,,,,outpatient,facility,,,34968.00,10490.40,14686.56,29722.80,,17134.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14686.56,,,percent of total billed charges,,Paid in addition to outpatient services ,17637.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14861.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26226.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,17484.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26226.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,29722.80,,,percent of total billed charges,,,16085.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SPINE BIO AVS 11X25X9MM,10108401,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SPINE BIO AVS 11X25X9MM,10108401,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ethanol Level,1011,CDM,0300,RC,G0480,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,66.70,258.61,,89.61,,,percent of total billed charges,,,112.14,,,fee schedule,,,71.34,,,fee schedule,,,238.64,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,236.87,,,fee schedule,,,108.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",114.38,,,fee schedule,,,258.61,,,fee schedule,,,,,,,,,112.14,,,fee schedule,,,,,,,,,147.02,,,fee schedule,,,233.44,,,fee schedule,,,108.75,,,percent of total billed charges,,,112.14,,,fee schedule,,,108.71,,,fee schedule,,,114.38,,,fee schedule,,,172.90,,,fee schedule,,,112.14,,,fee schedule,,,108.75,,,percent of total billed charges,,,,,,,,,114.38,,,fee schedule,,,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,125.87,,,fee schedule,,,112.14,,,fee schedule,,,,,,,,,111.0,,,fee schedule,,,112.14,,,fee schedule,,,,,,,,,113.26,,,fee schedule,,,,,,,,
Ethanol Level,1011,CDM,0300,RC,G0480,HCPCS,2041,EAPG,,,,outpatient,facility,,,145.00,43.50,82.28,141.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,120.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ethanol Level,1011,CDM,0300,RC,80320,CPT,,,,,,outpatient,facility,,,202.00,60.60,31.17,171.70,,124.84,,,percent of total billed charges,,,,,,,,service not payable,99.38,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,31.17,,,fee schedule,,,,,,,,,151.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,36.66,,,fee schedule,,,,,,,,service not payable,151.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,171.70,,,percent of total billed charges,,,92.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ethanol Level,1011,CDM,0300,RC,80320,CPT,2040,EAPG,,,,outpatient,facility,,,202.00,60.60,16.44,84.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,72.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ALLOGRAFT GEL 1CC X_3102-1101 X_STRYKER ORTHOPAEDI,10110171,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,2383.00,714.90,924.60,2025.55,,,,,,,,,,,,,,,,,,,,924.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1012.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1787.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1191.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2025.55,,,percent of total billed charges,,,1072.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT GEL 1CC X_3102-1101 X_STRYKER ORTHOPAEDI,10110171,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,2383.00,714.90,1012.78,2025.55,,,,,,,,,,,,,service not payable,,,,,,,1201.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1012.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1787.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1191.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1787.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2025.55,,,percent of total billed charges,,,1096.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT GEL 1CC X_3102-1101 X_STRYKER ORTHOPAEDI,10110171,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,2383.00,714.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X34MM,10110172,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X34MM,10110172,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 2.5X36MM,10110173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X36MM,10110173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDED 2.5X14MM X_IC2514 X_STRYKER ORTHOPAEDIC,10110174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDED 2.5X14MM X_IC2514 X_STRYKER ORTHOPAEDIC,10110174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN MINI 16X2.5MM,10110175,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN MINI 16X2.5MM,10110175,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 2.5X16MM X_IH2516 X_STRYKER ORTHOPAEDIC,10110176,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 2.5X16MM X_IH2516 X_STRYKER ORTHOPAEDIC,10110176,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG TALO-NAV LNG 29MM X_626762 X_STRYKER OR,10110177,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7013.00,2103.90,2721.04,5961.05,,3436.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2945.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2721.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2980.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5259.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3506.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5961.05,,,percent of total billed charges,,,3155.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG TALO-NAV LNG 29MM X_626762 X_STRYKER OR,10110177,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7013.00,2103.90,2945.46,5961.05,,3436.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2945.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3537.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2980.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5259.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3506.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5259.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5961.05,,,percent of total billed charges,,,3225.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SLIM-Y 4H 45MM X_626984 X_STRYKER ORTHOPAEDI,10110178,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4996.00,1498.80,1938.45,4246.60,,,,,,,,,,,,,,,,,,,,1938.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2123.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3747.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2498.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4246.60,,,percent of total billed charges,,,2248.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SLIM-Y 4H 45MM X_626984 X_STRYKER ORTHOPAEDI,10110178,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4996.00,1498.80,2123.30,4246.60,,,,,,,,,,,,,service not payable,,,,,,,2519.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2123.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3747.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2498.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3747.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4246.60,,,percent of total billed charges,,,2298.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.7X22MM X_656322 X_STRYKER ORTHOPAE,10110179,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.7X22MM X_656322 X_STRYKER ORTHOPAE,10110179,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.7X24MM X_656324 X_STRYKER ORTHOPAE,10110180,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.7X24MM X_656324 X_STRYKER ORTHOPAE,10110180,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T10 FT 3.5X22MM,10110181,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T10 FT 3.5X22MM,10110181,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT CARTIVA MTP 8MM X_CAR-08-US X_CARTIVA,10110183,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12024.00,3607.20,4665.31,10220.4,,5891.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5050.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4665.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5110.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9018.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6012.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10220.4,,,percent of total billed charges,,,5410.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT CARTIVA MTP 8MM X_CAR-08-US X_CARTIVA,10110183,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12024.00,3607.20,5050.08,10220.4,,5891.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5050.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6064.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5110.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9018.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6012.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9018.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10220.4,,,percent of total billed charges,,,5531.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT SM 6X18X12 5DEGREE X_6806818 X_NUVASIVE,10110184,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT SM 6X18X12 5DEGREE X_6806818 X_NUVASIVE,10110184,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT SM 7X18X12 5DEGREE X_6807818 X_NUVASIVE,10110185,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT SM 7X18X12 5DEGREE X_6807818 X_NUVASIVE,10110185,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB ATTUNE SZ8,10110187,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB ATTUNE SZ8,10110187,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE ALLODERM 16X20CM,10110188,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,22238.00,6671.40,8628.34,18902.30,,10896.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9339.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8628.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9451.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16678.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18902.30,,,percent of total billed charges,,,10007.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE ALLODERM 16X20CM,10110188,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,22238.00,6671.40,9339.96,22238.0,,10896.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9339.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11216.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9451.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16678.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16678.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18902.30,,,percent of total billed charges,,,10229.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,22238.0,,,percent of total billed charges,,,,,,,,service not payable,22238.0,,,percent of total billed charges,,
TISSUE ALLODERM 16X20CM,10110188,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,22238.00,6671.40,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VAS PROPATEN 7MMX60X80CM,10110189,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,8939.00,2681.70,3468.33,7598.15,,4380.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3754.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3468.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3799.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6704.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4469.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7598.15,,,percent of total billed charges,,,4022.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VAS PROPATEN 7MMX60X80CM,10110189,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,8939.00,2681.70,3754.38,7598.15,,4380.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3754.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4508.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3799.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6704.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4469.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6704.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7598.15,,,percent of total billed charges,,,4111.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VAS PROPATEN 8MMX40X70CM,10110190,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,11979.00,3593.70,4647.85,10182.15,,5869.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5031.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4647.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5091.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8984.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5989.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10182.15,,,percent of total billed charges,,,5390.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VAS PROPATEN 8MMX40X70CM,10110190,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,11979.00,3593.70,5031.18,10182.15,,5869.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5031.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6042.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5091.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8984.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5989.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8984.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10182.15,,,percent of total billed charges,,,5510.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 8X20X75,10110192,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB KEEL CMNTLESS MBT SZ6,10110193,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB KEEL CMNTLESS MBT SZ6,10110193,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA SZ 6.0 12.5MM,10110194,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA SZ 6.0 12.5MM,10110194,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIGHTROPE KNOTLESS SYNDESMOSIS,10110195,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIGHTROPE KNOTLESS SYNDESMOSIS,10110195,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 5X120MM X_S-50-120-120-P6 X_ABBOT,10110196,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4999.00,1499.70,1939.61,4249.15,,,,,,,,,,,,,,,,,,,,1939.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.15,,,percent of total billed charges,,,2249.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 5X120MM X_S-50-120-120-P6 X_ABBOT,10110196,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4999.00,1499.70,2124.57,4249.15,,,,,,,,,,,,,service not payable,,,,,,,2521.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4249.15,,,percent of total billed charges,,,2299.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 6X100MM,10110197,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4770.00,1431.00,1850.76,4054.5,,,,,,,,,,,,,,,,,,,,1850.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4054.5,,,percent of total billed charges,,,2146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 6X100MM,10110197,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4770.00,1431.00,2027.25,4054.5,,,,,,,,,,,,,service not payable,,,,,,,2405.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4054.5,,,percent of total billed charges,,,2194.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 6.5X100MM,10110198,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4770.00,1431.00,1850.76,4054.5,,,,,,,,,,,,,,,,,,,,1850.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4054.5,,,percent of total billed charges,,,2146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 6.5X100MM,10110198,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4770.00,1431.00,2027.25,4054.5,,,,,,,,,,,,,service not payable,,,,,,,2405.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4054.5,,,percent of total billed charges,,,2194.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK LP TI 3X26MM VAR,10110199,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK LP TI 3X26MM VAR,10110199,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 6.5X120MM X_S-65-120-120-P6 X_ABB,10110200,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4999.00,1499.70,1939.61,4249.15,,,,,,,,,,,,,,,,,,,,1939.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.15,,,percent of total billed charges,,,2249.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 6.5X120MM X_S-65-120-120-P6 X_ABB,10110200,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4999.00,1499.70,2124.57,4249.15,,,,,,,,,,,,,service not payable,,,,,,,2521.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4249.15,,,percent of total billed charges,,,2299.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 6.5X150MM X_S-65-150-120-P6 X_ABB,10110201,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4999.00,1499.70,1939.61,4249.15,,,,,,,,,,,,,,,,,,,,1939.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.15,,,percent of total billed charges,,,2249.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 6.5X150MM X_S-65-150-120-P6 X_ABB,10110201,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4999.00,1499.70,2124.57,4249.15,,,,,,,,,,,,,service not payable,,,,,,,2521.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4249.15,,,percent of total billed charges,,,2299.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUMP DRUG PROMATRA2 PROGRAM X_13827 X_FLOWONIX,10110203,CDM,0278,RC,E0783,HCPCS,,,,,,inpatient,facility,,,22948.00,6884.40,8903.82,19505.80,,11244.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9638.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8903.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11474.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19505.80,,,percent of total billed charges,,,10326.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUMP DRUG PROMATRA2 PROGRAM X_13827 X_FLOWONIX,10110203,CDM,0278,RC,E0783,HCPCS,,,,,,outpatient,facility,,,22948.00,6884.40,9638.16,19505.80,,11244.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9638.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11574.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11474.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17211.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19505.80,,,percent of total billed charges,,,10556.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 300ML,10110211,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 300ML,10110211,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 375ML,10110212,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 375ML,10110212,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 650ML,10110213,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 650ML,10110213,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Biopsy vaginal mucosa simple,10110581,CDM,0450,RC,57100,CPT,,,,,,outpatient,facility,,,1758.00,527.40,774.0,1494.3,,1086.44,,,percent of total billed charges,,,,,,,,,857.90,,,percent of total billed charges,,,886.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1318.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1318.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1494.3,,,percent of total billed charges,,,808.68,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Biopsy vaginal mucosa simple,10110581,CDM,0450,RC,57100,CPT,05413,APC,,,,outpatient,facility,,,1758.00,527.40,400.46,1917.81,,,,,,,,835.01,,,fee schedule,,,,,,,,,,,,,,,1756.58,,,fee schedule,,,400.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",851.71,,,fee schedule,,,1917.81,,,fee schedule,,,,,,,,,835.01,,,fee schedule,,,,,,,,,,,,,,,1731.12,,,fee schedule,,,,,,,,,835.01,,,fee schedule,,,400.46,,,fee schedule,,,851.71,,,fee schedule,,,,,,,,,835.01,,,fee schedule,,,,,,,,,400.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",851.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,835.01,,,fee schedule,,,,,,,,,,,,,,,835.01,,,fee schedule,,,,,,,,,843.33,,,fee schedule,,,,,,,,
Biopsy vaginal mucosa simple,10110581,CDM,0450,RC,57100,CPT,209,EAPG,,,,outpatient,facility,,,1758.00,527.40,633.64,2359.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2359.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2005.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,773.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,773.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,633.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,697.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ROD TENDON HNTR 5MMX25.5CM X_TR500000 X_WRIGHT MED,10110723,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5393.00,1617.90,2092.48,4584.05,,2642.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4044.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.05,,,percent of total billed charges,,,2426.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TENDON HNTR 5MMX25.5CM X_TR500000 X_WRIGHT MED,10110723,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5393.00,1617.90,2265.06,4584.05,,2642.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.05,,,percent of total billed charges,,,2480.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT DISTAL COMP THORACIC X_VAMC4444C100TU,10110724,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,35504.00,10651.20,13775.55,30178.40,,17396.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14911.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,13775.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15089.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26628.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17752.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30178.40,,,percent of total billed charges,,,15976.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT DISTAL COMP THORACIC X_VAMC4444C100TU,10110724,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,35504.00,10651.20,14911.68,30178.40,,17396.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14911.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,17908.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15089.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26628.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,17752.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26628.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,30178.40,,,percent of total billed charges,,,16331.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY STIMUBLAST 5ML X_ABS-2003-05 X_ARTHREX INC,10110725,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3584.00,1075.20,1390.59,3046.40,,,,,,,,,,,,,,,,,,,,1390.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1523.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2688.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1792.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3046.40,,,percent of total billed charges,,,1612.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY STIMUBLAST 5ML X_ABS-2003-05 X_ARTHREX INC,10110725,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3584.00,1075.20,1523.2,3046.40,,,,,,,,,,,,,service not payable,,,,,,,1807.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1523.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2688.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1792.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2688.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3046.40,,,percent of total billed charges,,,1648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE TRANS 7.5X45MM,10110726,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE TRANS 7.5X45MM,10110726,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL KIT LNG X_3530-0320S X_STRYKER ORTHOPAEDICS,10110728,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL KIT LNG X_3530-0320S X_STRYKER ORTHOPAEDICS,10110728,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FIX ANG TI 6X70MM,10110986,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FIX ANG TI 6X70MM,10110986,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL FIX AN 32.5X5MM,10110987,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL FIX AN 32.5X5MM,10110987,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AORTA ABD MAIN BODY PROXIMAL X_G32539 X_COOK MEDIC,10110990,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24041.00,7212.30,9327.91,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9327.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20434.85,,,percent of total billed charges,,,10818.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AORTA ABD MAIN BODY PROXIMAL X_G32539 X_COOK MEDIC,10110990,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24041.00,7212.30,10097.22,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12126.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20434.85,,,percent of total billed charges,,,11058.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIABAHNBX 6MMX29MMX135CM,10110991,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AORTA DESCENDING DISTAL X_G32561 X_COOK MEDICAL IN,10110992,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,12157.00,3647.10,4716.92,10333.45,,5956.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5105.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4716.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5166.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9117.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6078.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10333.45,,,percent of total billed charges,,,5470.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AORTA DESCENDING DISTAL X_G32561 X_COOK MEDICAL IN,10110992,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,12157.00,3647.10,5105.94,10333.45,,5956.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5105.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6131.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5166.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9117.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6078.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9117.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10333.45,,,percent of total billed charges,,,5592.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER VASC XL 20F 41X25CM,10110993,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,1962.00,588.60,833.85,1667.7,,1212.52,,,percent of total billed charges,,,,,,,,service not payable,957.46,,,percent of total billed charges,,,989.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,833.85,,,percent of total billed charges,,,,,,,,,1471.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,981.0,,,percent of total billed charges,,,,,,,,service not payable,1471.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1667.7,,,percent of total billed charges,,,902.52,,,percent of total billed charges,,,,,,,,,1275.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1275.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CODA 0.035MM 10FR 140CM,10110994,CDM,0272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,2420.00,726.00,1028.5,2057.0,,1495.56,,,percent of total billed charges,,,,,,,,service not payable,1180.96,,,percent of total billed charges,,,1220.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1028.5,,,percent of total billed charges,,,,,,,,,1815.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1210.0,,,percent of total billed charges,,,,,,,,service not payable,1815.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2057.0,,,percent of total billed charges,,,1113.2,,,percent of total billed charges,,,,,,,,,1573.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1573.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH STEERABLE 7FR X 55CM X_TG0705517 X_MEDTRONI,10110995,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE QFIX 1.8MM MINI,10110998,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE QFIX 1.8MM MINI,10110998,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT XL SUT ANCH QFIX 1.8MM MINI X_72290126 X_SMITH,10110999,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT XL SUT ANCH QFIX 1.8MM MINI X_72290126 X_SMITH,10110999,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM HIP SZ9 130D 165X38MM,10111302,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM HIP SZ9 130D 165X38MM,10111302,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NAT RETRO 13MMX20CM,10111303,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10819.00,3245.70,4197.77,9196.15,,5301.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4543.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4197.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8114.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5409.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9196.15,,,percent of total billed charges,,,4868.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NAT RETRO 13MMX20CM,10111303,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10819.00,3245.70,4543.98,9196.15,,5301.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4543.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5457.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4598.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8114.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5409.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8114.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9196.15,,,percent of total billed charges,,,4976.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL FIX ANGL 45X5MM,10111304,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL FIX ANGL 45X5MM,10111304,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FIX ANG FT 6X65MM,10111305,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FIX ANG FT 6X65MM,10111305,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FIX ANG HEX 6X35MM,10111306,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FIX ANG HEX 6X35MM,10111306,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FIX ANG TI 6X60MM,10111307,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FIX ANG TI 6X60MM,10111307,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
"GUIDEWIRE ADV LITE .014X190CM X_1044586 X_ABBOTT""""",10111308,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT FEM ART CRYO 23CM X_FA21-30 X_LIFENET,10111309,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,21213.00,6363.90,8230.64,18031.05,,10394.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8909.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8230.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9015.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15909.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18031.05,,,percent of total billed charges,,,9545.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT FEM ART CRYO 23CM X_FA21-30 X_LIFENET,10111309,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,21213.00,6363.90,8909.46,18031.05,,10394.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8909.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10699.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9015.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15909.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15909.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18031.05,,,percent of total billed charges,,,9757.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE XIA 3 RADIAL 6X35MM,10111310,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE XIA 3 RADIAL 6X35MM,10111310,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 18.5 X_ZLB00 18.5 X_ABBOTT,10111311,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 18.5 X_ZLB00 18.5 X_ABBOTT,10111311,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1956.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1956.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,service not payable,1760.40,,,fee schedule,,,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS 24.0 X_ZXR00 24.0 X_ABBOTT,10111312,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 24.0 X_ZXR00 24.0 X_ABBOTT,10111312,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
CAGE BASE TI 6X38X28 15DEG X_6952615 X_NUVASIVE,10111313,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE BASE TI 6X38X28 15DEG X_6952615 X_NUVASIVE,10111313,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT BASE 50X20 VARI X_6955202 X_NUVASIVE,10111314,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT BASE 50X20 VARI X_6955202 X_NUVASIVE,10111314,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 4.0X65MM X_658065 X_STRYKER,10111315,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 4.0X65MM X_658065 X_STRYKER,10111315,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 7.0X90MM X_658590 X_STRYKER,10111316,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 7.0X90MM X_658590 X_STRYKER,10111316,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 7.0X95MM X_658595 X_STRYKER,10111317,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 7.0X95MM X_658595 X_STRYKER,10111317,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE ASAHI 17X17X300CM,10111358,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,574.74,,,percent of total billed charges,,,,,,,,service not payable,453.84,,,percent of total billed charges,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,604.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,604.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP BX Exam,10112102,CDM,0490,RC,38222,CPT,,,,,,outpatient,facility,,,4236.00,1270.80,1948.56,3795.64,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,2136.64,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3600.60,,,percent of total billed charges,,,1948.56,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP BX Exam,10112102,CDM,0490,RC,38222,CPT,05073,APC,,,,outpatient,facility,,,4236.00,1270.80,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
SP BX Exam,10112102,CDM,0490,RC,38222,CPT,124,EAPG,,,,outpatient,facility,,,4236.00,1270.80,1513.42,6811.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6811.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5789.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1513.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1664.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP BX Exam,10112107,CDM,0490,RC,38222,CPT,,,,,50  ,outpatient,facility,,,8472.00,2541.60,2958.0,7201.20,,5693.46,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4368.51,,,case rate,,,4273.28,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2958.0,,,case rate,,,,,,,,,6354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3480.0,,,case rate,,,,,,,,,6354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7201.20,,,percent of total billed charges,,,3897.12,,,percent of total billed charges,,,,,,,,,4566.0,,,case rate,,,,,,,,,,,,,,,4018.5,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP BX Exam,10112107,CDM,0490,RC,38222,CPT,05073,APC,,,50  ,outpatient,facility,,,8472.00,2541.60,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
SP BX Exam,10112107,CDM,0490,RC,38222,CPT,124,EAPG,,,50  ,outpatient,facility,,,8472.00,2541.60,2270.13,10217.40,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.40,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8684.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2270.13,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2497.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10112111,CDM,0490,RC,32998,CPT,,,,,,outpatient,facility,,,14105.00,4231.50,5463.36,12795.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,7114.56,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,10578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,10578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11989.25,,,percent of total billed charges,,,6488.30,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10112111,CDM,0490,RC,32998,CPT,05361,APC,,,,outpatient,facility,,,14105.00,4231.50,5366.60,12850.20,,,,,,,,5594.96,,,fee schedule,,,,,,,,,,,,,,,11769.88,,,fee schedule,,,5366.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5706.86,,,fee schedule,,,12850.20,,,fee schedule,,,,,,,,,5594.96,,,fee schedule,,,,,,,,,,,,,,,11599.30,,,fee schedule,,,,,,,,,5594.96,,,fee schedule,,,5366.60,,,fee schedule,,,5706.86,,,fee schedule,,,,,,,,,5594.96,,,fee schedule,,,,,,,,,5366.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5706.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5594.96,,,fee schedule,,,,,,,,,,,,,,,5594.96,,,fee schedule,,,,,,,,,5650.68,,,fee schedule,,,,,,,,
CT Exam,10112111,CDM,0490,RC,32998,CPT,70,EAPG,,,,outpatient,facility,,,14105.00,4231.50,7346.79,13526.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13526.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,11497.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7346.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7346.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7346.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10584.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,11642.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ambulance Ground,10112302,CDM,0540,RC,A0428,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,441.87,,,percent of total billed charges,,,,,,,,service not payable,348.92,,,percent of total billed charges,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,357.5,,,percent of total billed charges,,,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,517.0,,,per diem,,Paid in addition to outpatient services ,350.0,,,per diem,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ambulance Ground,10112302,CDM,0540,RC,A0428,HCPCS,1030,EAPG,,,,outpatient,facility,,,715.00,214.50,17.56,387.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,387.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ambulance Air by HELICOPTER,10112303,CDM,0545,RC,A0431,HCPCS,,,,,,outpatient,facility,,,3761.00,1128.30,1598.42,3378.0,,2324.30,,,percent of total billed charges,,,,,,,,service not payable,1835.37,,,percent of total billed charges,,,1897.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1598.42,,,percent of total billed charges,,,,,,,,,2820.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1880.5,,,percent of total billed charges,,,,,,,,service not payable,2820.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3196.85,,,percent of total billed charges,,,1730.06,,,percent of total billed charges,,,,,,,,,3378.0,,,per diem,,Paid in addition to outpatient services ,2300.0,,,per diem,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ambulance Air by HELICOPTER,10112303,CDM,0545,RC,A0431,HCPCS,1030,EAPG,,,,outpatient,facility,,,3761.00,1128.30,17.56,3761.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3761.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3761.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
eCrossmatch,10112473,CDM,0300,RC,86923,CPT,,,,,,outpatient,facility,,,82.00,24.60,34.12,179.01,,50.68,,,percent of total billed charges,,,,,,,,,40.34,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.12,,,fee schedule,,,,,,,,,61.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.13,,,fee schedule,,,,,,,,,61.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
eCrossmatch,10112473,CDM,0300,RC,86923,CPT,05672,APC,,,,outpatient,facility,,,82.00,24.60,82.0,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,82.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,82.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
eCrossmatch,10112473,CDM,0300,RC,86923,CPT,2043,EAPG,,,,outpatient,facility,,,82.00,24.60,82.0,608.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,517.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,124.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,137.08,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SEALANT HEMOSTATIC FLOSEAL 5ML,10112847,CDM,0623,RC,A6250,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,736.66,,,percent of total billed charges,,,,,,,,service not payable,581.70,,,percent of total billed charges,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,774.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,774.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA X_MSZ-F700 X_ALLERGAN INC,10112849,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPIRA X_MSZ-F700 X_ALLERGAN INC,10112849,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPIRA X_MSZ-F695 X_ALLERGAN INC,10112850,CDM,0270,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TIGHTROPE CONCAVE RND X_AR-1588TB-3 X_ARTHR,10112851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1225.00,367.50,475.30,1041.25,,,,,,,,,,,,,,,,,,,,475.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,918.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,612.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1041.25,,,percent of total billed charges,,,551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUTTON TIGHTROPE CONCAVE RND X_AR-1588TB-3 X_ARTHR,10112851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1225.00,367.50,520.62,1041.25,,,,,,,,,,,,,service not payable,,,,,,,617.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,520.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,918.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,612.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,918.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1041.25,,,percent of total billed charges,,,563.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM GLBL UNI STD SZ16 137MM,10112852,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM GLBL UNI STD SZ16 137MM,10112852,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD GLBL UNI SZ16 135D RVRS,10112853,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLBL UNI SZ16 135D RVRS,10112853,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 16MM X_48811116 X_STRYKER SPINE,10112855,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 16MM X_48811116 X_STRYKER SPINE,10112855,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COFLEX SZ16MM X_UQI00016 X_PARADIGM SPINE,10112856,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,20325.00,6097.50,7886.10,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7886.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17276.25,,,percent of total billed charges,,,9146.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COFLEX SZ16MM X_UQI00016 X_PARADIGM SPINE,10112856,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,20325.00,6097.50,8536.5,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10251.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17276.25,,,percent of total billed charges,,,9349.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COFLEX SZ8MM X_UQI00008 X_PARADIGM SPINE,10112857,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20325.00,6097.50,7886.10,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7886.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17276.25,,,percent of total billed charges,,,9146.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COFLEX SZ8MM X_UQI00008 X_PARADIGM SPINE,10112857,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20325.00,6097.50,8536.5,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10251.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17276.25,,,percent of total billed charges,,,9349.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PHYSIOMESH 10X10 X_OPHY1010 X_ETHICON,10112858,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1910.00,573.00,741.08,1623.5,,,,,,,,,,,,,,,,,,,,741.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,811.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1432.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1623.5,,,percent of total billed charges,,,859.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHYSIOMESH 10X10 X_OPHY1010 X_ETHICON,10112858,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1910.00,573.00,811.75,1623.5,,,,,,,,,,,,,service not payable,,,,,,,963.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,811.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1432.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1432.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1623.5,,,percent of total billed charges,,,878.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING SACRUM BRDR 9.2X9.2IN,10112859,CDM,0623,RC,A6213,HCPCS,,,,,,outpatient,facility,,,74.00,22.20,31.45,62.90,,45.73,,,percent of total billed charges,,,,,,,,service not payable,36.11,,,percent of total billed charges,,,37.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,31.45,,,percent of total billed charges,,,,,,,,,55.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,37.0,,,percent of total billed charges,,,,,,,,service not payable,55.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,,34.04,,,percent of total billed charges,,,,,,,,,48.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,48.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 8X14X40 8DEG X_5184408 X_NUVASIVE,10112860,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,13113.00,3933.90,5087.84,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5087.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,,5900.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 8X14X40 8DEG X_5184408 X_NUVASIVE,10112860,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5507.46,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR CL LGN SZ3-4 11MM,10112861,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR CL LGN SZ3-4 11MM,10112861,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE XIA 3 TI RAD 6X60MM,10112862,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE XIA 3 TI RAD 6X60MM,10112862,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT CANC CHIP CRS 15ML4-10MM,10112863,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,1771.00,531.30,687.15,1505.35,,,,,,,,,,,,,,,,,,,,687.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1328.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1505.35,,,percent of total billed charges,,,796.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT CANC CHIP CRS 15ML4-10MM,10112863,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,1771.00,531.30,752.67,1505.35,,,,,,,,,,,,,service not payable,,,,,,,893.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,752.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1328.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1328.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1505.35,,,percent of total billed charges,,,814.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT CANC CHIP CRS 15ML4-10MM,10112863,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,1771.00,531.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR BILIARY CRE RX 8-10MM,10112864,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,996.22,,,percent of total billed charges,,,,,,,,service not payable,786.66,,,percent of total billed charges,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,1047.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1047.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DILATOR BILIARY CRE RX 10-12MM,10112865,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,996.22,,,percent of total billed charges,,,,,,,,service not payable,786.66,,,percent of total billed charges,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,1047.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1047.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DILATOR BILIARY CRE RX 12-15MM,10112866,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,996.22,,,percent of total billed charges,,,,,,,,service not payable,786.66,,,percent of total billed charges,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,1047.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1047.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE TEAR DROP 3.0MMX100CM,10112867,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,713.00,213.90,303.02,606.05,,440.63,,,percent of total billed charges,,,,,,,,service not payable,347.94,,,percent of total billed charges,,,359.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.02,,,percent of total billed charges,,,,,,,,,534.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,356.5,,,percent of total billed charges,,,,,,,,service not payable,534.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,606.05,,,percent of total billed charges,,,327.98,,,percent of total billed charges,,,,,,,,,463.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,463.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Stent Endograft Iliac Limb Aorta SS Fluropalymer V,10112868,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10572.00,3171.60,4101.94,8986.20,,5180.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4440.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4101.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4493.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7929.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5286.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8986.20,,,percent of total billed charges,,,4757.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Stent Endograft Iliac Limb Aorta SS Fluropalymer V,10112868,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10572.00,3171.60,4440.24,8986.20,,5180.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4440.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5332.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4493.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7929.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5286.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7929.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8986.20,,,percent of total billed charges,,,4863.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDE CAROTID 6F 90CM,10112877,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,640.00,192.00,272.0,544.0,,395.52,,,percent of total billed charges,,,,,,,,service not payable,312.32,,,percent of total billed charges,,,322.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,272.0,,,percent of total billed charges,,,,,,,,,480.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,320.0,,,percent of total billed charges,,,,,,,,service not payable,480.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,544.0,,,percent of total billed charges,,,294.40,,,percent of total billed charges,,,,,,,,,416.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,416.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS PERCEPTA PACEMAKER QUAD X_PERCEPTAMRIQDMMQM X_,10112883,CDM,0278,RC,C1722,HCPCS,,,,,,inpatient,facility,,,26707.00,8012.10,10362.32,22700.95,,13086.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11216.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10362.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20030.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13353.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22700.95,,,percent of total billed charges,,,12018.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS PERCEPTA PACEMAKER QUAD X_PERCEPTAMRIQDMMQM X_,10112883,CDM,0278,RC,C1722,HCPCS,,,,,,outpatient,facility,,,26707.00,8012.10,11216.94,22700.95,,13086.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11216.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13471.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11350.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20030.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13353.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20030.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,22700.95,,,percent of total billed charges,,,12285.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DYNAGEN X4 / ACUITY X4 ENDOTAK,10112884,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,34968.00,10490.40,13567.58,29722.80,,17134.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14686.56,,,percent of total billed charges,,Paid in addition to inpatient services ,13567.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14861.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26226.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17484.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29722.80,,,percent of total billed charges,,,15735.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DYNAGEN X4 / ACUITY X4 ENDOTAK,10112884,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,34968.00,10490.40,14686.56,29722.80,,17134.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14686.56,,,percent of total billed charges,,Paid in addition to outpatient services ,17637.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14861.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26226.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,17484.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26226.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,29722.80,,,percent of total billed charges,,,16085.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM MOD DXTEND D14 SZ2,10112885,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM MOD DXTEND D14 SZ2,10112885,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEM KNEE PS SZ6 RT X_5516-F-602 X_STRYKER,10112887,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEM KNEE PS SZ6 RT X_5516-F-602 X_STRYKER,10112887,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DX SWVLK INST KIT 3.5X8.5MM,10112888,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1502.00,450.60,582.78,1276.7,,,,,,,,,,,,,,,,,,,,582.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276.7,,,percent of total billed charges,,,675.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DX SWVLK INST KIT 3.5X8.5MM,10112888,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,,,,,,,,,,,,service not payable,,,,,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR DX SWIVELOCK 8.5X3.5MM,10112889,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR DX SWIVELOCK 8.5X3.5MM,10112889,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE FIXATION HAMMERTOE SM,10112890,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6523.00,1956.90,2530.92,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2530.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5544.55,,,percent of total billed charges,,,2935.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE FIXATION HAMMERTOE SM,10112890,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6523.00,1956.90,2739.66,5544.55,,3196.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2739.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3290.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2772.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4892.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5544.55,,,percent of total billed charges,,,3000.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDED 2.5X12MM X_IC2512 X_STRYKER,10112891,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDED 2.5X12MM X_IC2512 X_STRYKER,10112891,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 3X30MM,10112892,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 3X30MM,10112892,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT STEM 7.5MM 2OD X_496S275 X_WRIGHT MEDICA,10112893,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6986.00,2095.80,2710.57,5938.10,,3423.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2710.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2969.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5239.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3493.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5938.10,,,percent of total billed charges,,,3143.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT STEM 7.5MM 2OD X_496S275 X_WRIGHT MEDICA,10112893,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6986.00,2095.80,2934.12,5938.10,,3423.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3523.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2969.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5239.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3493.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5239.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5938.10,,,percent of total billed charges,,,3213.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE EVOLVE TRIAD RAD HD 24MM,10112895,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4534.00,1360.20,1759.19,3853.90,,,,,,,,,,,,,,,,,,,,1759.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1926.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3400.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2267.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3853.90,,,percent of total billed charges,,,2040.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE EVOLVE TRIAD RAD HD 24MM,10112895,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4534.00,1360.20,1926.95,3853.90,,,,,,,,,,,,,service not payable,,,,,,,2286.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1926.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3400.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2267.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3400.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3853.90,,,percent of total billed charges,,,2085.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD 32 NEURO STIM KIT 50CM,10113386,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,16063.00,4818.90,6232.44,13653.55,,7870.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6746.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6232.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6826.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12047.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8031.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13653.55,,,percent of total billed charges,,,7228.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD 32 NEURO STIM KIT 50CM,10113386,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,16063.00,4818.90,6746.46,13653.55,,7870.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6746.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8102.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6826.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12047.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8031.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12047.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13653.55,,,percent of total billed charges,,,7388.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE TAK ANCHOR DX BC SZ1 X_AR-8934BCNF X_ARTHRE,10113387,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE TAK ANCHOR DX BC SZ1 X_AR-8934BCNF X_ARTHRE,10113387,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM SHLDR GLBL UNI SZ10 142DG,10113560,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM SHLDR GLBL UNI SZ10 142DG,10113560,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE BIOSYNC EVANS 20X20X8MM,10113562,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7196.00,2158.80,2792.05,6116.60,,3526.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3022.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2792.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5397.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3598.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6116.60,,,percent of total billed charges,,,3238.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE BIOSYNC EVANS 20X20X8MM,10113562,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7196.00,2158.80,3022.32,6116.60,,3526.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3022.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3629.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3058.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5397.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3598.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5397.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6116.60,,,percent of total billed charges,,,3310.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE GLIDE SURFACE T2/T2 10MM,10113565,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE GLIDE SURFACE T2/T2 10MM,10113565,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR COMP SZ4 LT 66.5X60X3MM X_NX010Z X_AESCULAP,10113567,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR COMP SZ4 LT 66.5X60X3MM X_NX010Z X_AESCULAP,10113567,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE GLDNG VEGA PS 10MM X_NX220 X_AESCULAP,10113569,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE GLDNG VEGA PS 10MM X_NX220 X_AESCULAP,10113569,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI 25MM X_48552025 X_STRYKER SPINE,10113571,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI 25MM X_48552025 X_STRYKER SPINE,10113571,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X30MM,10113572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X30MM,10113572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4X38MM X_663038 X_STRYKER,10113576,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6079.00,1823.70,2358.65,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2358.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5167.15,,,percent of total billed charges,,,2735.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4X38MM X_663038 X_STRYKER,10113576,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6079.00,1823.70,2553.18,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3066.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5167.15,,,percent of total billed charges,,,2796.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE TRINITY SM 1.0ML X_410001 X_MUSCULOSKET,10113577,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3454.00,1036.20,1340.15,2935.90,,,,,,,,,,,,,,,,,,,,1340.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1467.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2590.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1727.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2935.90,,,percent of total billed charges,,,1554.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE TRINITY SM 1.0ML X_410001 X_MUSCULOSKET,10113577,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3454.00,1036.20,1467.95,2935.90,,,,,,,,,,,,,service not payable,,,,,,,1742.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1467.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2590.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1727.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2590.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2935.90,,,percent of total billed charges,,,1588.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT COMP THORACIC X_VAMC4242C150TU X_MEDTR,10114096,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,38782.00,11634.60,15047.42,32964.70,,19003.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16288.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15047.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16482.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29086.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19391.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32964.70,,,percent of total billed charges,,,17451.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT COMP THORACIC X_VAMC4242C150TU X_MEDTR,10114096,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,38782.00,11634.60,16288.44,32964.70,,19003.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16288.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19561.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16482.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,29086.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19391.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29086.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32964.70,,,percent of total billed charges,,,17839.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN LONG HALF 5X40MM X_7106-5409 X_SMITH NEPHEW,10114097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN LONG HALF 5X40MM X_7106-5409 X_SMITH NEPHEW,10114097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Bacterial Vaginosis Screen - MH/WH/FH,10114299,CDM,0300,RC,87205,CPT,,,,,,outpatient,facility,,,51.00,15.30,4.06,43.35,,18.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.18,,,fee schedule,,,13.54,,,fee schedule,,,8.90,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,8.84,,,fee schedule,,,4.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.26,,,fee schedule,,,9.65,,,fee schedule,,,,,,,,,4.18,,,fee schedule,,,,,,,,,5.47,,,fee schedule,,,8.71,,,fee schedule,,,38.25,,,percent of total billed charges,,,4.18,,,fee schedule,,,4.06,,,fee schedule,,,4.26,,,fee schedule,,,6.44,,,fee schedule,,,4.18,,,fee schedule,,,38.25,,,percent of total billed charges,,,,,,,,,4.26,,,fee schedule,,,,,,,,,43.35,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,4.70,,,fee schedule,,,4.18,,,fee schedule,,,,,,,,,4.14,,,fee schedule,,,4.18,,,fee schedule,,,,,,,,,4.22,,,fee schedule,,,,,,,,
Bacterial Vaginosis Screen - MH/WH/FH,10114299,CDM,0300,RC,87205,CPT,396,EAPG,,,,outpatient,facility,,,51.00,15.30,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insulin Like Growth Factor 1 (IGF 1),10114354,CDM,0300,RC,84305,CPT,,,,,,outpatient,facility,,,76.00,22.80,20.20,76.0,,76.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,20.83,,,fee schedule,,,67.41,,,fee schedule,,,44.34,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,44.01,,,fee schedule,,,20.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.25,,,fee schedule,,,48.05,,,fee schedule,,,,,,,,,20.83,,,fee schedule,,,,,,,,,27.39,,,fee schedule,,,43.37,,,fee schedule,,,57.0,,,percent of total billed charges,,,20.83,,,fee schedule,,,20.20,,,fee schedule,,,21.25,,,fee schedule,,,32.21,,,fee schedule,,,20.83,,,fee schedule,,,57.0,,,percent of total billed charges,,,,,,,,,21.25,,,fee schedule,,,,,,,,,64.60,,,percent of total billed charges,,,34.96,,,percent of total billed charges,,,,,,,,,23.39,,,fee schedule,,,20.83,,,fee schedule,,,,,,,,,20.62,,,fee schedule,,,20.83,,,fee schedule,,,,,,,,,21.04,,,fee schedule,,,,,,,,
Insulin Like Growth Factor 1 (IGF 1),10114354,CDM,0300,RC,84305,CPT,398,EAPG,,,,outpatient,facility,,,76.00,22.80,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW 4.0X14MM X_6791714 X_NUVASIVE,10115160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.0X14MM X_6791714 X_NUVASIVE,10115160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTERLOCK SM 7X17X14 X_6790227 X_NUVASIVE,10115161,CDM,0278,RC,C2628,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTERLOCK SM 7X17X14 X_6790227 X_NUVASIVE,10115161,CDM,0278,RC,C2628,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM REFLUX MGMNT SZ13 X_LXMC13 X_TORAX MEDICAL,10115163,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM REFLUX MGMNT SZ13 X_LXMC13 X_TORAX MEDICAL,10115163,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM REFLUX MGMNT SZ14 X_LXMC14 X_TORAX MEDICAL,10115164,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM REFLUX MGMNT SZ14 X_LXMC14 X_TORAX MEDICAL,10115164,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM REFLUX MGMNT SZ15 X_LXMC15 X_TORAX MEDICAL,10115165,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM REFLUX MGMNT SZ15 X_LXMC15 X_TORAX MEDICAL,10115165,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM REFLUX MGMNT SZ16 X_LXMC16 X_TORAX MEDICAL,10115166,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM REFLUX MGMNT SZ16 X_LXMC16 X_TORAX MEDICAL,10115166,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM REFLUX MGMNT SZ17 X_LXMC17 X_TORAX MEDICAL,10115167,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM REFLUX MGMNT SZ17 X_LXMC17 X_TORAX MEDICAL,10115167,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB DYNAGEN CARDIOVERT IS-1,10115169,CDM,0278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,28630.00,8589.00,11108.44,24335.5,,14028.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12024.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11108.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14315.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24335.5,,,percent of total billed charges,,,12883.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB DYNAGEN CARDIOVERT IS-1,10115169,CDM,0278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,28630.00,8589.00,12024.6,24335.5,,14028.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12024.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14440.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12167.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21472.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14315.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21472.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24335.5,,,percent of total billed charges,,,13169.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE CAPSTONE 14X26MM X_2991426 X_SOFAMOR DANEK,1011536,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10162.00,3048.60,3942.86,8637.70,,4979.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4268.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3942.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4318.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8637.70,,,percent of total billed charges,,,4572.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE CAPSTONE 14X26MM X_2991426 X_SOFAMOR DANEK,1011536,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10162.00,3048.60,4268.04,8637.70,,4979.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4268.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4318.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5081.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER CYLOS DR-T X_349806 X_BIOTRONIK,1011537,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,22887.00,6866.10,8880.16,19453.95,,11214.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9612.54,,,percent of total billed charges,,Paid in addition to inpatient services ,8880.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9726.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17165.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11443.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19453.95,,,percent of total billed charges,,,10299.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER CYLOS DR-T X_349806 X_BIOTRONIK,1011537,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,22887.00,6866.10,9612.54,19453.95,,11214.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9612.54,,,percent of total billed charges,,Paid in addition to outpatient services ,11544.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9726.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17165.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11443.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17165.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19453.95,,,percent of total billed charges,,,10528.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7X14MM X_41113010 X_WRIGHT MEDICAL,1011540,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,436.00,130.80,169.17,370.60,,,,,,,,,,,,,,,,,,,,169.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.60,,,percent of total billed charges,,,196.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7X14MM X_41113010 X_WRIGHT MEDICAL,1011540,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,436.00,130.80,185.30,370.60,,,,,,,,,,,,,service not payable,,,,,,,219.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,370.60,,,percent of total billed charges,,,200.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF 3X15MM X_71063151 X_RICHARDS MFG CO,1011543,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,607.00,182.10,235.52,515.95,,,,,,,,,,,,,,,,,,,,235.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,455.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,303.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,515.95,,,percent of total billed charges,,,273.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF 3X15MM X_71063151 X_RICHARDS MFG CO,1011543,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,607.00,182.10,257.97,515.95,,,,,,,,,,,,,service not payable,,,,,,,306.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,257.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,455.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,303.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,455.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,515.95,,,percent of total billed charges,,,279.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP FREEDOM 10.5-5MM,1011544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2884.00,865.20,1118.99,2451.40,,,,,,,,,,,,,,,,,,,,1118.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1225.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2163.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1442.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2451.40,,,percent of total billed charges,,,1297.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP FREEDOM 10.5-5MM,1011544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2884.00,865.20,1225.7,2451.40,,,,,,,,,,,,,service not payable,,,,,,,1454.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1225.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2163.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1442.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2163.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2451.40,,,percent of total billed charges,,,1326.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BAR 6X75MM X_71065075 X_RICHARDS MFG CO,1011545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,569.00,170.70,220.77,483.65,,,,,,,,,,,,,,,,,,,,220.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,426.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,284.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.65,,,percent of total billed charges,,,256.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BAR 6X75MM X_71065075 X_RICHARDS MFG CO,1011545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,569.00,170.70,241.82,483.65,,,,,,,,,,,,,service not payable,,,,,,,287.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,241.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,426.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,284.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,426.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,483.65,,,percent of total billed charges,,,261.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 10 HOLE X_71829440 X_RICHARDS MFG CO,1011546,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,362.00,108.60,140.46,307.70,,,,,,,,,,,,,,,,,,,,140.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.70,,,percent of total billed charges,,,162.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 10 HOLE X_71829440 X_RICHARDS MFG CO,1011546,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,362.00,108.60,153.85,307.70,,,,,,,,,,,,,service not payable,,,,,,,182.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,271.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,307.70,,,percent of total billed charges,,,166.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE ROD 2.0X900MM X_71118280 X_RICHARDS MFG C,1011547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,640.00,192.00,248.32,544.0,,,,,,,,,,,,,,,,,,,,248.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,480.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,320.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.0,,,percent of total billed charges,,,288.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE ROD 2.0X900MM X_71118280 X_RICHARDS MFG C,1011547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,640.00,192.00,272.0,544.0,,,,,,,,,,,,,service not payable,,,,,,,322.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,480.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,320.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,480.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,544.0,,,percent of total billed charges,,,294.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7 X_71822310 X_RICHARDS MFG CO,1011550,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,568.00,170.40,220.38,482.80,,,,,,,,,,,,,,,,,,,,220.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,426.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,284.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.80,,,percent of total billed charges,,,255.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7 X_71822310 X_RICHARDS MFG CO,1011550,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,568.00,170.40,241.40,482.80,,,,,,,,,,,,,service not payable,,,,,,,286.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,241.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,426.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,284.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,426.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,482.80,,,percent of total billed charges,,,261.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZG X_5956-17-02 X_ZIMMER-DAVIS,1011551,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZG X_5956-17-02 X_ZIMMER-DAVIS,1011551,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL FLUTED X_5996-48-02 X_ZIMMER-D,1011552,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL FLUTED X_5996-48-02 X_ZIMMER-D,1011552,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN ST FH HEX 7.3X60MM,1011553,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,647.00,194.10,251.04,549.95,,,,,,,,,,,,,,,,,,,,251.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,485.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,323.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.95,,,percent of total billed charges,,,291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN ST FH HEX 7.3X60MM,1011553,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,647.00,194.10,274.97,549.95,,,,,,,,,,,,,service not payable,,,,,,,326.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,274.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,485.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,323.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,485.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,549.95,,,percent of total billed charges,,,297.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAPSTONE 12X26MM X_2991226 X_SOFAMOR DANEK,1011554,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,9851.00,2955.30,3822.19,8373.35,,4826.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4137.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3822.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4186.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7388.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4925.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8373.35,,,percent of total billed charges,,,4432.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAPSTONE 12X26MM X_2991226 X_SOFAMOR DANEK,1011554,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,9851.00,2955.30,4137.42,8373.35,,4826.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4137.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4968.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4186.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7388.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4925.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7388.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8373.35,,,percent of total billed charges,,,4531.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS PROSTATIC UROLIFT,10118096,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS PROSTATIC UROLIFT,10118096,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON LCKG 4.5X32MM X_AR-8545-32 X_ARTHREX INC,10118098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LCKG 4.5X32MM X_AR-8545-32 X_ARTHREX INC,10118098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON LCKG 4.5X46MM X_AR-8545-46 X_ARTHREX INC,10118099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LCKG 4.5X46MM X_AR-8545-46 X_ARTHREX INC,10118099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANKLE FUS ANT LT 5HOLE,10118100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6803.00,2040.90,2639.56,5782.55,,3333.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2857.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2639.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2891.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5102.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3401.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5782.55,,,percent of total billed charges,,,3061.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANKLE FUS ANT LT 5HOLE,10118100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6803.00,2040.90,2857.26,5782.55,,3333.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2857.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3431.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2891.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5102.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3401.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5102.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5782.55,,,percent of total billed charges,,,3129.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 4.5X20MM X_AR-8545L-20 X_ARTHREX INC,10118101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 4.5X20MM X_AR-8545L-20 X_ARTHREX INC,10118101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 5.5X55MM,10118102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 5.5X55MM,10118102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TROCAR TIP .094 2.4MMX12IN X_AR-8967K-12,10118103,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH TOUR GD 7F 9MM,10118104,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE TIBIAL SZ4 LT X_71424004 X_SMITH NEPHEW,10118105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10972.00,3291.60,4257.14,9326.20,,5376.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4608.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4257.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4663.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8229.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5486.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9326.20,,,percent of total billed charges,,,4937.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE TIBIAL SZ4 LT X_71424004 X_SMITH NEPHEW,10118105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10972.00,3291.60,4608.24,9326.20,,5376.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4608.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5534.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4663.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8229.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5486.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8229.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9326.20,,,percent of total billed charges,,,5047.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ3-4 15MM X_71453281 X_SMITH NEP,10118106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ3-4 15MM X_71453281 X_SMITH NEP,10118106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PTX X_ZISV6-35-125-6-100-PTX X_COOK MED,10118108,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5885.00,1765.50,2283.38,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2283.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5002.25,,,percent of total billed charges,,,2648.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PTX X_ZISV6-35-125-6-100-PTX X_COOK MED,10118108,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5885.00,1765.50,2471.70,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2968.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5002.25,,,percent of total billed charges,,,2707.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Orthotic/Prosth management and/or training upper,10118256,CDM,0420,RC,97763,CPT,,,,,GP  ,outpatient,facility,,,137.00,41.10,43.61,260.0,,84.67,,,percent of total billed charges,,,46.23,,,fee schedule,,,67.40,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,97.25,,,fee schedule,,,43.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",47.25,,,fee schedule,,,106.38,,,fee schedule,,,,,,,,,46.32,,,fee schedule,,,,,,,,,173.0,,,per diem,,,95.84,,,fee schedule,,,102.75,,,percent of total billed charges,,,46.23,,,fee schedule,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,204.0,,,per diem,,,46.32,,,fee schedule,,,102.75,,,percent of total billed charges,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,46.32,,,fee schedule,,,,,,,,,229.0,,,per diem,,,46.23,,,fee schedule,,,,,,,,,46.23,,,fee schedule,,,,,,,,
Orthotic/Prosth management and/or training upper,10118256,CDM,0420,RC,97763,CPT,269,EAPG,,,GP  ,outpatient,facility,,,137.00,41.10,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Orthotic/Prosth management and/or training upper,10118257,CDM,0430,RC,97763,CPT,,,,,GO  ,outpatient,facility,,,137.00,41.10,43.61,260.0,,84.67,,,percent of total billed charges,,,46.23,,,fee schedule,,,67.40,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,97.25,,,fee schedule,,,43.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",47.25,,,fee schedule,,,106.38,,,fee schedule,,,,,,,,,46.32,,,fee schedule,,,,,,,,,173.0,,,per diem,,,95.84,,,fee schedule,,,102.75,,,percent of total billed charges,,,46.23,,,fee schedule,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,204.0,,,per diem,,,46.32,,,fee schedule,,,102.75,,,percent of total billed charges,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,46.32,,,fee schedule,,,,,,,,,229.0,,,per diem,,,46.23,,,fee schedule,,,,,,,,,46.23,,,fee schedule,,,,,,,,
Orthotic/Prosth management and/or training upper,10118257,CDM,0430,RC,97763,CPT,269,EAPG,,,GO  ,outpatient,facility,,,137.00,41.10,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bone Marrow Biopsy and Asp Bil,10118356,CDM,0490,RC,38222,CPT,,,,,50  ,outpatient,facility,,,8472.00,2541.60,2958.0,7201.20,,5693.46,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4368.51,,,case rate,,,4273.28,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2958.0,,,case rate,,,,,,,,,6354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3480.0,,,case rate,,,,,,,,,6354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7201.20,,,percent of total billed charges,,,3897.12,,,percent of total billed charges,,,,,,,,,4566.0,,,case rate,,,,,,,,,,,,,,,4018.5,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Bone Marrow Biopsy and Asp Bil,10118356,CDM,0490,RC,38222,CPT,05073,APC,,,50  ,outpatient,facility,,,8472.00,2541.60,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
Bone Marrow Biopsy and Asp Bil,10118356,CDM,0490,RC,38222,CPT,124,EAPG,,,50  ,outpatient,facility,,,8472.00,2541.60,2270.13,10217.40,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.40,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8684.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2270.13,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2497.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bone Marrow Biopsy and Asp,10118358,CDM,0490,RC,38222,CPT,,,,,,outpatient,facility,,,4236.00,1270.80,1948.56,3795.64,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,2136.64,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3600.60,,,percent of total billed charges,,,1948.56,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Bone Marrow Biopsy and Asp,10118358,CDM,0490,RC,38222,CPT,05073,APC,,,,outpatient,facility,,,4236.00,1270.80,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
Bone Marrow Biopsy and Asp,10118358,CDM,0490,RC,38222,CPT,124,EAPG,,,,outpatient,facility,,,4236.00,1270.80,1513.42,6811.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6811.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5789.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1513.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1664.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bone Marrow Biopsy and Asp Bil,10118363,CDM,0490,RC,38222,CPT,,,,,50  ,outpatient,facility,,,8472.00,2541.60,2958.0,7201.20,,5693.46,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4368.51,,,case rate,,,4273.28,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2958.0,,,case rate,,,,,,,,,6354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3480.0,,,case rate,,,,,,,,,6354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7201.20,,,percent of total billed charges,,,3897.12,,,percent of total billed charges,,,,,,,,,4566.0,,,case rate,,,,,,,,,,,,,,,4018.5,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Bone Marrow Biopsy and Asp Bil,10118363,CDM,0490,RC,38222,CPT,05073,APC,,,50  ,outpatient,facility,,,8472.00,2541.60,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
Bone Marrow Biopsy and Asp Bil,10118363,CDM,0490,RC,38222,CPT,124,EAPG,,,50  ,outpatient,facility,,,8472.00,2541.60,2270.13,10217.40,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.40,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8684.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3615.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2270.13,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2497.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bone Marrow Biopsy and Asp,10118364,CDM,0490,RC,38222,CPT,,,,,,outpatient,facility,,,4236.00,1270.80,1948.56,3795.64,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,2136.64,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3600.60,,,percent of total billed charges,,,1948.56,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Bone Marrow Biopsy and Asp,10118364,CDM,0490,RC,38222,CPT,05073,APC,,,,outpatient,facility,,,4236.00,1270.80,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
Bone Marrow Biopsy and Asp,10118364,CDM,0490,RC,38222,CPT,124,EAPG,,,,outpatient,facility,,,4236.00,1270.80,1513.42,6811.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6811.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5789.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1513.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1664.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP BX Exam,10118493,CDM,0490,RC,32561,CPT,,,,,,outpatient,facility,,,1926.00,577.80,885.96,2912.34,,1926.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,971.47,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1444.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1444.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1637.10,,,percent of total billed charges,,,885.96,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP BX Exam,10118493,CDM,0490,RC,32561,CPT,05181,APC,,,,outpatient,facility,,,1926.00,577.80,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
SP BX Exam,10118493,CDM,0490,RC,32561,CPT,68,EAPG,,,,outpatient,facility,,,1926.00,577.80,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP BX Exam,10118495,CDM,0490,RC,32562,CPT,,,,,,outpatient,facility,,,1926.00,577.80,885.96,2912.34,,1926.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,971.47,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1444.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1444.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1637.10,,,percent of total billed charges,,,885.96,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP BX Exam,10118495,CDM,0490,RC,32562,CPT,05181,APC,,,,outpatient,facility,,,1926.00,577.80,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
SP BX Exam,10118495,CDM,0490,RC,32562,CPT,68,EAPG,,,,outpatient,facility,,,1926.00,577.80,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HEAD GBL UNI ECCENTRIC 44X15MM,10118639,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GBL UNI ECCENTRIC 44X15MM,10118639,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CORE SLIDING 9MM UHMPWE X_400-143F X_STRYKER,10118643,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5866.00,1759.80,2276.01,4986.10,,2874.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2463.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2276.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2493.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2933.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4986.10,,,percent of total billed charges,,,2639.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CORE SLIDING 9MM UHMPWE X_400-143F X_STRYKER,10118643,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5866.00,1759.80,2463.72,4986.10,,2874.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2463.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2958.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2493.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4399.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2933.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4399.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4986.10,,,percent of total billed charges,,,2698.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X45MM,10118644,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X45MM,10118644,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB 11H RT X_P53-203-R011 X_PARAGON 28,10120100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6134.00,1840.20,2379.99,5213.90,,3005.66,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2576.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2379.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2606.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4600.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3067.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5213.90,,,percent of total billed charges,,,2760.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB 11H RT X_P53-203-R011 X_PARAGON 28,10120100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6134.00,1840.20,2576.28,5213.90,,3005.66,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2576.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3093.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2606.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4600.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3067.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4600.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5213.90,,,percent of total billed charges,,,2821.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST HEADED 3.0X18MM X_P20-130-018S X_PARAGON,10120101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1435.00,430.50,556.78,1219.75,,,,,,,,,,,,,,,,,,,,556.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,609.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1076.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,717.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1219.75,,,percent of total billed charges,,,645.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST HEADED 3.0X18MM X_P20-130-018S X_PARAGON,10120101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1435.00,430.50,609.88,1219.75,,,,,,,,,,,,,service not payable,,,,,,,723.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,609.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1076.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,717.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1076.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1219.75,,,percent of total billed charges,,,660.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG PLT R3CON 3.5X12MM  X_P50-353-3512 X_PA,10120102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1270.00,381.00,492.76,1079.5,,,,,,,,,,,,,,,,,,,,492.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,952.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,635.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.5,,,percent of total billed charges,,,571.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG PLT R3CON 3.5X12MM  X_P50-353-3512 X_PA,10120102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1270.00,381.00,539.75,1079.5,,,,,,,,,,,,,service not payable,,,,,,,640.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,539.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,952.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,635.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,952.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1079.5,,,percent of total billed charges,,,584.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING PLATE 3.5X14MM,10120103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1270.00,381.00,492.76,1079.5,,,,,,,,,,,,,,,,,,,,492.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,952.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,635.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.5,,,percent of total billed charges,,,571.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING PLATE 3.5X14MM,10120103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1270.00,381.00,539.75,1079.5,,,,,,,,,,,,,service not payable,,,,,,,640.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,539.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,952.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,635.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,952.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1079.5,,,percent of total billed charges,,,584.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG R3CON 3.5X16MM X _ P50-453-3516X_PA,10120104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG R3CON 3.5X16MM X _ P50-453-3516X_PA,10120104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CEMENTED SZ9,10120105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CEMENTED SZ9,10120105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP ST HDLS 7X55MM X_658355 X_STRYKER ORTHO,10120106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP ST HDLS 7X55MM X_658355 X_STRYKER ORTHO,10120106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE COMP UT 2.0X150MM,10120107,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,591.00,177.30,251.18,502.35,,365.24,,,percent of total billed charges,,,,,,,,service not payable,288.41,,,percent of total billed charges,,,298.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,251.18,,,percent of total billed charges,,,,,,,,,443.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,443.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,502.35,,,percent of total billed charges,,,271.86,,,percent of total billed charges,,,,,,,,,384.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,384.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLESS 4X34MM,10120108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLESS 4X34MM,10120108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLESS 4X44MM,10120109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLESS 4X44MM,10120109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 4.0X46MM X_IH4046 X_STRYKER ORTHOPAEDIC,10120110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 4.0X46MM X_IH4046 X_STRYKER ORTHOPAEDIC,10120110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR 5.5MM BIOSTEON X_3910-200-082 X_STRYKER,10120111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2377.00,713.10,922.28,2020.45,,,,,,,,,,,,,,,,,,,,922.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1010.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1188.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,,1069.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR 5.5MM BIOSTEON X_3910-200-082 X_STRYKER,10120111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2377.00,713.10,1010.22,2020.45,,,,,,,,,,,,,service not payable,,,,,,,1198.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1010.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1188.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1782.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,,1093.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX BONE BIO 4 10ML X_PS51010 X_STRYKER SPINE,10120112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12366.00,3709.80,4798.01,10511.1,,6059.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5193.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4798.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5255.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9274.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6183.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10511.1,,,percent of total billed charges,,,5564.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX BONE BIO 4 10ML X_PS51010 X_STRYKER SPINE,10120112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12366.00,3709.80,5193.72,10511.1,,6059.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5193.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6237.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5255.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9274.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6183.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9274.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10511.1,,,percent of total billed charges,,,5688.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX BONE BIO 4 5ML X_PS51005 X_STRYKER SPINE,10120113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6184.00,1855.20,2399.39,5256.40,,3030.16,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2597.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2399.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2628.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4638.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3092.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5256.40,,,percent of total billed charges,,,2782.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX BONE BIO 4 5ML X_PS51005 X_STRYKER SPINE,10120113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6184.00,1855.20,2597.28,5256.40,,3030.16,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2597.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3119.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2628.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4638.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3092.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4638.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5256.40,,,percent of total billed charges,,,2844.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 9X23X6 DEG X_48951096 X_STRYKER SPIN,10120114,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 9X23X6 DEG X_48951096 X_STRYKER SPIN,10120114,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 8X23X6 DEG X_48951086 X_STRYKER SPIN,10120115,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 8X23X6 DEG X_48951086 X_STRYKER SPIN,10120115,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TENDON ANTERIOR TIBIALIS X_447-13808-LA X_TRANZGRA,10120118,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,7901.00,2370.30,3065.59,6715.85,,3871.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3318.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3065.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3357.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6715.85,,,percent of total billed charges,,,3555.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TENDON ANTERIOR TIBIALIS X_447-13808-LA X_TRANZGRA,10120118,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,7901.00,2370.30,3318.42,6715.85,,3871.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3318.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3985.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3357.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6715.85,,,percent of total billed charges,,,3634.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF- Biopsy soft tissue of neck or thorax,10120264,CDM,0761,RC,21550,CPT,,,,,,outpatient,facility,,,2393.00,717.90,118.0,2034.05,,1478.87,,,percent of total billed charges,,,,,,,,,1167.78,,,percent of total billed charges,,,1207.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1017.02,,,percent of total billed charges,,,,,,,,,1794.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1196.5,,,percent of total billed charges,,,,,,,,,1794.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2034.05,,,percent of total billed charges,,,1100.78,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
BCF- Biopsy soft tissue of neck or thorax,10120264,CDM,0761,RC,21550,CPT,05072,APC,,,,outpatient,facility,,,2393.00,717.90,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
BCF- Biopsy soft tissue of neck or thorax,10120264,CDM,0761,RC,21550,CPT,69,EAPG,,,,outpatient,facility,,,2393.00,717.90,2393.0,7202.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7202.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6121.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2393.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2393.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2393.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3315.14,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3646.65,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPACER AVS PEEK 4D 8.0X25.0MM,10120431,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PEEK 4D 8.0X25.0MM,10120431,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE XIA 3 TI RAD 6X70MM,10120432,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE XIA 3 TI RAD 6X70MM,10120432,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAVICLE NRW STR 8H X_70-0299 X_ACCUMED,10120433,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4205.00,1261.50,1631.54,3574.25,,,,,,,,,,,,,,,,,,,,1631.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3574.25,,,percent of total billed charges,,,1892.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAVICLE NRW STR 8H X_70-0299 X_ACCUMED,10120433,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4205.00,1261.50,1787.12,3574.25,,,,,,,,,,,,,service not payable,,,,,,,2121.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3574.25,,,percent of total billed charges,,,1934.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NLK HEXALOBE 3.0X10MM X_30-0279 X_ACCUMED,10120434,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NLK HEXALOBE 3.0X10MM X_30-0279 X_ACCUMED,10120434,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NKL HEXALOBE 3.0X8MM X_30-0278 X_ACCUMED,10120435,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NKL HEXALOBE 3.0X8MM X_30-0278 X_ACCUMED,10120435,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 9H LP LCKG X_7482-0409 X_SMITH NEPHEW,10120436,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3795.00,1138.50,1472.46,3225.75,,,,,,,,,,,,,,,,,,,,1472.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1612.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2846.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1897.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3225.75,,,percent of total billed charges,,,1707.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 9H LP LCKG X_7482-0409 X_SMITH NEPHEW,10120436,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3795.00,1138.50,1612.88,3225.75,,,,,,,,,,,,,service not payable,,,,,,,1914.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1612.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2846.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1897.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2846.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3225.75,,,percent of total billed charges,,,1745.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEXALOBE 3.0X24MM X_30-0286 X_ACCUMED,10120438,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEXALOBE 3.0X24MM X_30-0286 X_ACCUMED,10120438,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TAP ELBOW SYS 3.5MM SCRW,10120439,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TAP ELBOW SYS 3.5MM SCRW,10120439,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB DIST LCKG 5H 91MM,10120440,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB DIST LCKG 5H 91MM,10120440,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE 4.0 LT 8FR 100CM,10120441,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE 4.0 RT 8FR 100CM,10120442,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE 3.5 RT 8FR 100CM X_LA8JR35SH X_MEDTRONI,10120443,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE 3.5 LT 8FR 100CM X_LA8JL35SH X_MEDTRONI,10120444,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEEDLE KOPANS 20G 15CM,10120446,CDM,0278,RC,C1819,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE KOPANS 20G 15CM,10120446,CDM,0278,RC,C1819,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 4.0X42MM X_663042 X_STRYKER ORTHOP,10120448,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6079.00,1823.70,2358.65,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2358.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5167.15,,,percent of total billed charges,,,2735.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 4.0X42MM X_663042 X_STRYKER ORTHOP,10120448,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6079.00,1823.70,2553.18,5167.15,,2978.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2553.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3066.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2583.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4559.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3039.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4559.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5167.15,,,percent of total billed charges,,,2796.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Y-PLATE BROAD 3H X_626993 X_STRYKER,10120658,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5865.00,1759.50,2275.62,4985.25,,2873.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2463.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2275.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2492.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4398.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2932.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4985.25,,,percent of total billed charges,,,2639.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Y-PLATE BROAD 3H X_626993 X_STRYKER,10120658,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5865.00,1759.50,2463.30,4985.25,,2873.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2463.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2958.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2492.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4398.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2932.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4398.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4985.25,,,percent of total billed charges,,,2697.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP HDLESS 4X38MM,10120659,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP HDLESS 4X38MM,10120659,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP AS VEGA FEMUR SZ5 64.8MM,10120661,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP AS VEGA FEMUR SZ5 64.8MM,10120661,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE GLDNG VEGA PS 12MM X_NX131 X_BRAUN MEDICAL,10120662,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE GLDNG VEGA PS 12MM X_NX131 X_BRAUN MEDICAL,10120662,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATEAU TIB CEM SZT3 75X48MM X_NX055Z X_BRAUN MEDI,10120663,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATEAU TIB CEM SZT3 75X48MM X_NX055Z X_BRAUN MEDI,10120663,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LID CADDY 6.5X80MM X_7117-7322 X_SMITH NEPHE,10120664,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2016.00,604.80,782.21,1713.60,,,,,,,,,,,,,,,,,,,,782.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,856.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1512.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1008.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1713.60,,,percent of total billed charges,,,907.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LID CADDY 6.5X80MM X_7117-7322 X_SMITH NEPHE,10120664,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2016.00,604.80,856.80,1713.60,,,,,,,,,,,,,service not payable,,,,,,,1016.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,856.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1512.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1008.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1512.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1713.60,,,percent of total billed charges,,,927.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FB CR SZ8 5MM X_1516-20-805 X_DEPUY,10120665,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FB CR SZ8 5MM X_1516-20-805 X_DEPUY,10120665,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3.0X20 X_71103220S X_SMITH NEPHEW,10120940,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1078.00,323.40,418.26,916.30,,,,,,,,,,,,,,,,,,,,418.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916.30,,,percent of total billed charges,,,485.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3.0X20 X_71103220S X_SMITH NEPHEW,10120940,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1078.00,323.40,458.15,916.30,,,,,,,,,,,,,service not payable,,,,,,,543.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,458.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,808.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,539.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,808.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,916.30,,,percent of total billed charges,,,495.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EVENT MONITOR APPLICATION,10120973,CDM,0480,RC,93799,CPT,,,,,,outpatient,facility,,,440.00,132.00,187.0,2075.0,,271.92,,,percent of total billed charges,,,,,,,,,214.72,,,percent of total billed charges,,,221.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,,,,,,,,330.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.0,,,percent of total billed charges,,,,,,,,,330.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,374.0,,,percent of total billed charges,,,202.40,,,percent of total billed charges,,,,,,,,,2075.0,,,per diem,,,,,,,,,,,,,,,1826.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
EVENT MONITOR APPLICATION,10120973,CDM,0480,RC,93799,CPT,05721,APC,,,,outpatient,facility,,,440.00,132.00,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
EVENT MONITOR APPLICATION,10120973,CDM,0480,RC,93799,CPT,413,EAPG,,,,outpatient,facility,,,440.00,132.00,37.41,195.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,165.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,37.41,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,37.41,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,61.38,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,67.52,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW BONE CANN MINI 18X3.0MM,10124106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN MINI 18X3.0MM,10124106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS VIABAHN VBX 7MM,10124107,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS VIABAHN VBX 7MM,10124107,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10MMX39MMX135CM,10124108,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10MMX39MMX135CM,10124108,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN VBX 7X59MM 7FR X_BXA075902A X_W L GO,10124109,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN VBX 7X59MM 7FR X_BXA075902A X_W L GO,10124109,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 9MMX59MM 135CM,10124110,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 9MMX59MM 135CM,10124110,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10MMX59MMX135CM,10124111,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10MMX59MMX135CM,10124111,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3X16MM X_AR-8830-16 X_ARTHREX INC,10126103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3X16MM X_AR-8830-16 X_ARTHREX INC,10126103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 SIZE 7,10126104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 SIZE 7,10126104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NL LP 4.5X42MM,10126105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NL LP 4.5X42MM,10126105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET HEM HA TI SOLID 60G X_500-11-60G X_STRY,10126106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET HEM HA TI SOLID 60G X_500-11-60G X_STRY,10126106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER EUSTACHIAN TUBE BALLOON X_EU061655 X_GYRU,10132101,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,5931.00,1779.30,2520.68,5041.35,,3665.36,,,percent of total billed charges,,,,,,,,service not payable,2894.33,,,percent of total billed charges,,,2991.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2520.68,,,percent of total billed charges,,,,,,,,,4448.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2965.5,,,percent of total billed charges,,,,,,,,service not payable,4448.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5041.35,,,percent of total billed charges,,,2728.26,,,percent of total billed charges,,,,,,,,,3855.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3855.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7.0X85MM,10132102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7.0X85MM,10132102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW QCKFIX CANC PT 3.0X24MM X_AR-8730-24PT X_ART,10132103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW QCKFIX CANC PT 3.0X24MM X_AR-8730-24PT X_ART,10132103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT MATRIX 5CC BIO4,10132104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10145.00,3043.50,3936.26,8623.25,,4971.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4260.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3936.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4311.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7608.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5072.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8623.25,,,percent of total billed charges,,,4565.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT MATRIX 5CC BIO4,10132104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10145.00,3043.50,4260.90,8623.25,,4971.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4260.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5117.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4311.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7608.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5072.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7608.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8623.25,,,percent of total billed charges,,,4666.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS CANNUL 4.0MM40MM,10132105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS CANNUL 4.0MM40MM,10132105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER DYNAGEN CRT-D DF4,10132106,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,32455.00,9736.50,12592.54,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13631.1,,,percent of total billed charges,,Paid in addition to inpatient services ,12592.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27586.75,,,percent of total billed charges,,,14604.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER DYNAGEN CRT-D DF4,10132106,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,32455.00,9736.50,13631.1,27586.75,,15902.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13631.1,,,percent of total billed charges,,Paid in addition to outpatient services ,16370.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13793.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16227.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24341.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27586.75,,,percent of total billed charges,,,14929.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 CEMENTLESS SZ3,10132166,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 CEMENTLESS SZ3,10132166,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 7X23X0 DEG X_48951070 X_STRYKER,10132167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 7X23X0 DEG X_48951070 X_STRYKER,10132167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE PEEK TL 14X30X4 DEG X_48370144 X_STRYKER,10132168,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PEEK TL 14X30X4 DEG X_48370144 X_STRYKER,10132168,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LP NONLOCK 5.5X45MM,10132169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LP NONLOCK 5.5X45MM,10132169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 CEMENTLESS SZ4,10132177,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 CEMENTLESS SZ4,10132177,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL KIT 6FR 24CM X_5556024 X_OLYMPUS AM,10132179,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,396.00,118.80,153.65,336.60,,,,,,,,,,,,,,,,,,,,153.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,297.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.60,,,percent of total billed charges,,,178.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL KIT 6FR 24CM X_5556024 X_OLYMPUS AM,10132179,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,396.00,118.80,168.30,336.60,,,,,,,,,,,,,service not payable,,,,,,,199.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,168.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,297.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,198.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,297.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,336.60,,,percent of total billed charges,,,182.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Injection anesthetic agent suprascapular nerve,10132380,CDM,0761,RC,64418,CPT,,,,,,outpatient,facility,,,1659.00,497.70,118.0,1410.15,,1025.26,,,percent of total billed charges,,,,,,,,,809.59,,,percent of total billed charges,,,836.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.08,,,percent of total billed charges,,,,,,,,,1244.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,829.5,,,percent of total billed charges,,,,,,,,,1244.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1410.15,,,percent of total billed charges,,,763.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Injection anesthetic agent suprascapular nerve,10132380,CDM,0761,RC,64418,CPT,05442,APC,,,,outpatient,facility,,,1659.00,497.70,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Injection anesthetic agent suprascapular nerve,10132380,CDM,0761,RC,64418,CPT,214,EAPG,,,,outpatient,facility,,,1659.00,497.70,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ALLOGRAFT TRIAD LUMBAR 10X11X25 X_1004803 X_NUVASI,10134100,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,5179.00,1553.70,2009.45,4402.15,,2537.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2175.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2009.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2201.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3884.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2589.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4402.15,,,percent of total billed charges,,,2330.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT TRIAD LUMBAR 10X11X25 X_1004803 X_NUVASI,10134100,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,5179.00,1553.70,2175.18,4402.15,,2537.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2175.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2612.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2201.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3884.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2589.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3884.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4402.15,,,percent of total billed charges,,,2382.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL 48X24MM X_5552-S-4824 X_STRYKER,10134101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3667.00,1100.10,1422.80,3116.95,,,,,,,,,,,,,,,,,,,,1422.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3116.95,,,percent of total billed charges,,,1650.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL 48X24MM X_5552-S-4824 X_STRYKER,10134101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3667.00,1100.10,1558.47,3116.95,,,,,,,,,,,,,service not payable,,,,,,,1849.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3116.95,,,percent of total billed charges,,,1686.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSION CERVICAL 14X16X8MM X_1000-00-0816 X_,10134102,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSION CERVICAL 14X16X8MM X_1000-00-0816 X_,10134102,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANN TI 3.5 X 14MM,10134103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN TI 3.5 X 14MM,10134103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT 2.7X30MM X_AR-8827-30 X_ARTHREX INC,10136136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT 2.7X30MM X_AR-8827-30 X_ARTHREX INC,10136136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 4.0X26MM X_AR-8740-26H X_ARTHREX INC,10136137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 4.0X26MM X_AR-8740-26H X_ARTHREX INC,10136137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT PERI-LOC 7X100MM,10136138,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1124.00,337.20,436.11,955.40,,,,,,,,,,,,,,,,,,,,436.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,955.40,,,percent of total billed charges,,,505.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT PERI-LOC 7X100MM,10136138,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1124.00,337.20,477.70,955.40,,,,,,,,,,,,,service not payable,,,,,,,566.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,955.40,,,percent of total billed charges,,,517.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7.0X50MM X_7112-7050 X_SMITH NEPHEW,10136139,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7.0X50MM X_7112-7050 X_SMITH NEPHEW,10136139,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7.0X40MM X_7112-7040 X_SMITH NEPHEW,10136140,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7.0X40MM X_7112-7040 X_SMITH NEPHEW,10136140,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSION CERVICAL 12X14X7MM X_1000-00-0714 X_,10136141,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSION CERVICAL 12X14X7MM X_1000-00-0714 X_,10136141,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHRINKER KNEE ABOVE,10136142,CDM,0274,RC,L8460,HCPCS,,,,,,inpatient,facility,,,363.00,108.90,140.84,308.55,,,,,,,,,,,,,,,,,,,,140.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.55,,,percent of total billed charges,,,163.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHRINKER KNEE ABOVE,10136142,CDM,0274,RC,L8460,HCPCS,,,,,,outpatient,facility,,,363.00,108.90,54.93,308.55,,,,,,,,78.71,,,fee schedule,,,,,,,,,183.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,165.58,,,fee schedule,,,54.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",80.28,,,fee schedule,,,180.78,,,fee schedule,,,,,,,,,78.71,,,fee schedule,,,,,,,,,154.28,,,percent of total billed charges,,Paid in addition to outpatient services ,163.18,,,fee schedule,,,272.25,,,percent of total billed charges,,,78.71,,,fee schedule,,,54.93,,,fee schedule,,,80.28,,,fee schedule,,,181.5,,,percent of total billed charges,,Paid in addition to outpatient services ,78.71,,,fee schedule,,,272.25,,,percent of total billed charges,,,54.93,,,fee schedule,,,80.28,,,fee schedule,,,,,,,,,308.55,,,percent of total billed charges,,,166.98,,,percent of total billed charges,,,,,,,,,,,,,,,78.71,,,fee schedule,,,,,,,,,,,,,,,78.71,,,fee schedule,,,,,,,,,79.5,,,fee schedule,,,,,,,,
CATH ANGLED GLIDE 150CM 4F,10136143,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,271.00,81.30,115.17,230.35,,167.48,,,percent of total billed charges,,,,,,,,service not payable,132.25,,,percent of total billed charges,,,136.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,115.17,,,percent of total billed charges,,,,,,,,,203.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,135.5,,,percent of total billed charges,,,,,,,,service not payable,203.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,230.35,,,percent of total billed charges,,,124.66,,,percent of total billed charges,,,,,,,,,176.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,176.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RAO-CTA DUAL SYRINGE FAST LOAD X_ 17347 X_ 351705,10138211,CDM,0272,RC,A4209,HCPCS,,,,,,outpatient,facility,,,100.00,30.00,42.5,85.0,,61.80,,,percent of total billed charges,,,,,,,,service not payable,48.80,,,percent of total billed charges,,,50.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.5,,,percent of total billed charges,,,,,,,,,75.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,50.0,,,percent of total billed charges,,,,,,,,service not payable,75.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,85.0,,,percent of total billed charges,,,46.0,,,percent of total billed charges,,,,,,,,,65.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,65.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 SIZE 6,10138215,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 SIZE 6,10138215,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT IPSL LEG 28X14.5MMX16CM,10138216,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,37886.00,11365.80,14699.77,32203.10,,18564.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15912.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14699.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16101.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28414.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18943.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32203.10,,,percent of total billed charges,,,17048.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT IPSL LEG 28X14.5MMX16CM,10138216,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,37886.00,11365.80,15912.12,32203.10,,18564.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15912.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19109.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16101.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28414.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18943.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28414.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32203.10,,,percent of total billed charges,,,17427.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT CNTRA LEG 14.5MMX12CM,10138217,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15536.00,4660.80,6027.97,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6027.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13205.6,,,percent of total billed charges,,,6991.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT CNTRA LEG 14.5MMX12CM,10138217,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15536.00,4660.80,6525.12,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7836.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13205.6,,,percent of total billed charges,,,7146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS AAA GORE EXCL X_PLL161007 X_GORE ME,10138218,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10933.00,3279.90,4242.00,9293.05,,5357.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4591.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4242.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4646.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8199.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5466.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9293.05,,,percent of total billed charges,,,4919.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS AAA GORE EXCL X_PLL161007 X_GORE ME,10138218,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10933.00,3279.90,4591.86,9293.05,,5357.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4591.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5514.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4646.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8199.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5466.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8199.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9293.05,,,percent of total billed charges,,,5029.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT EPTFE BIFUR 16X14MMX7CM,10138219,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10933.00,3279.90,4242.00,9293.05,,5357.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4591.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4242.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4646.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8199.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5466.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9293.05,,,percent of total billed charges,,,4919.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT EPTFE BIFUR 16X14MMX7CM,10138219,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10933.00,3279.90,4591.86,9293.05,,5357.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4591.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5514.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4646.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8199.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5466.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8199.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9293.05,,,percent of total billed charges,,,5029.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Maternal Screen AFP-HCG-Estriol-Inhibin A,10138246,CDM,0310,RC,81511,CPT,,,,,,outpatient,facility,,,105.00,31.50,48.30,320.13,,64.89,,,percent of total billed charges,,,102.90,,,fee schedule,,,51.66,,,fee schedule,,,320.13,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,217.35,,,fee schedule,,,,,,,,service not payable,104.96,,,fee schedule,,,237.30,,,fee schedule,,,,,,,,,102.90,,,fee schedule,,,,,,,,,197.57,,,fee schedule,,,214.20,,,fee schedule,,,78.75,,,percent of total billed charges,,,102.90,,,fee schedule,,,,,,,,service not payable,104.96,,,fee schedule,,,232.35,,,fee schedule,,,102.90,,,fee schedule,,,78.75,,,percent of total billed charges,,,,,,,,service not payable,104.96,,,fee schedule,,,,,,,,,89.25,,,percent of total billed charges,,,48.30,,,percent of total billed charges,,,,,,,,,168.85,,,fee schedule,,,102.90,,,fee schedule,,,,,,,,,148.90,,,fee schedule,,,102.90,,,fee schedule,,,,,,,,,102.90,,,fee schedule,,,,,,,,
Maternal Screen AFP-HCG-Estriol-Inhibin A,10138246,CDM,0310,RC,81511,CPT,386,EAPG,,,,outpatient,facility,,,105.00,31.50,105.0,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,105.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,105.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANN 3X14MM X_AR-8830-14 X_ARTHREX INC,10140174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3X14MM X_AR-8830-14 X_ARTHREX INC,10140174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CHARGER SPINAL STIMULATOR,10140175,CDM,0272,RC,C1787,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,2026.42,,,percent of total billed charges,,,,,,,,service not payable,1600.15,,,percent of total billed charges,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 10X60 75CM,10140176,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2160.28,4320.55,,3141.29,,,percent of total billed charges,,,,,,,,service not payable,2480.5,,,percent of total billed charges,,,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2541.5,,,percent of total billed charges,,,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,3303.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3303.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 8X60 75CM,10140177,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2160.28,4320.55,,3141.29,,,percent of total billed charges,,,,,,,,service not payable,2480.5,,,percent of total billed charges,,,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2541.5,,,percent of total billed charges,,,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,3303.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3303.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUPERA 4.5X120MM X_SC-45-120-120-PS X_AB,10140178,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4999.00,1499.70,1939.61,4249.15,,,,,,,,,,,,,,,,,,,,1939.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.15,,,percent of total billed charges,,,2249.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUPERA 4.5X120MM X_SC-45-120-120-PS X_AB,10140178,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4999.00,1499.70,2124.57,4249.15,,,,,,,,,,,,,service not payable,,,,,,,2521.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2124.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3749.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2499.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3749.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4249.15,,,percent of total billed charges,,,2299.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEM DIST A/LAT 10H RT,10140181,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11058.00,3317.40,4290.50,9399.30,,5418.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4644.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4290.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4699.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8293.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5529.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9399.30,,,percent of total billed charges,,,4976.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEM DIST A/LAT 10H RT,10140181,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11058.00,3317.40,4644.36,9399.30,,5418.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4644.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5577.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4699.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8293.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5529.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8293.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9399.30,,,percent of total billed charges,,,5086.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5.0X55MM X_661155 X_STRYKER ORTHOPAEDIC,10140182,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5.0X55MM X_661155 X_STRYKER ORTHOPAEDIC,10140182,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK AXSOS TI 5.0X95MM,10140183,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X95MM,10140183,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X34MM,10140184,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X34MM,10140184,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X48MM X_661748 X_STRYKER ORTHOPAE,10140185,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X48MM X_661748 X_STRYKER ORTHOPAE,10140185,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 4.5X90MM X_661790 X_STRYKER ORTHOPAE,10140186,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 4.5X90MM X_661790 X_STRYKER ORTHOPAE,10140186,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT STAPLE BONE 12X10X10MM X_SK121010 X_STRYKER OR,10140187,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6115.00,1834.50,2372.62,5197.75,,2996.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2568.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2372.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2598.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4586.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5197.75,,,percent of total billed charges,,,2751.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT STAPLE BONE 12X10X10MM X_SK121010 X_STRYKER OR,10140187,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6115.00,1834.50,2568.30,5197.75,,2996.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2568.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3084.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2598.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4586.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3057.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4586.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5197.75,,,percent of total billed charges,,,2812.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL CANN HUMERAL PROX RT 8X150MM X_1832-1045S X_S,10140188,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5510.00,1653.00,2137.88,4683.5,,2699.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2314.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2341.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4132.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2755.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4683.5,,,percent of total billed charges,,,2479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL CANN HUMERAL PROX RT 8X150MM X_1832-1045S X_S,10140188,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5510.00,1653.00,2314.20,4683.5,,2699.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2314.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2779.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2341.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4132.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2755.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4132.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4683.5,,,percent of total billed charges,,,2534.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5X32MM X_30-0244 X_ACCUMED,10140189,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X32MM X_30-0244 X_ACCUMED,10140189,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB TSplus  X3 6 11MM,10140468,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB TSplus  X3 6 11MM,10140468,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT EAR PONTO BHX X_M52171 X_OTICON MEDICAL,10140469,CDM,0278,RC,L8610,HCPCS,,,,,,inpatient,facility,,,13277.00,3983.10,5151.48,11285.45,,6505.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5576.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5151.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5642.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9957.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6638.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11285.45,,,percent of total billed charges,,,5974.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT EAR PONTO BHX X_M52171 X_OTICON MEDICAL,10140469,CDM,0278,RC,L8610,HCPCS,,,,,,outpatient,facility,,,13277.00,3983.10,5576.34,11285.45,,6505.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5576.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6696.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5642.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9957.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6638.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9957.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11285.45,,,percent of total billed charges,,,6107.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ RESTORE TORIC X_SV25T6-19.5 X_ALCON LAB IN,10140470,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ RESTORE TORIC X_SV25T6-19.5 X_ALCON LAB IN,10140470,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTRAVERSE 3.5X300MM X_U81303H30 X_BARD,10140471,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 10.0,10140472,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 10.0,10140472,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB VIGILANT X4 CRT 73.8G,10140475,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,31444.00,9433.20,12200.27,26727.40,,15407.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13206.48,,,percent of total billed charges,,Paid in addition to inpatient services ,12200.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13363.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23583.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15722.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26727.40,,,percent of total billed charges,,,14149.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB VIGILANT X4 CRT 73.8G,10140475,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,31444.00,9433.20,13206.48,26727.40,,15407.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13206.48,,,percent of total billed charges,,Paid in addition to outpatient services ,15860.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13363.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23583.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15722.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23583.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26727.40,,,percent of total billed charges,,,14464.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECLIPSE STD SZ 4,10142160,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECLIPSE STD SZ 4,10142160,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECLIPSE STD SZ 5,10142161,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECLIPSE STD SZ 5,10142161,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ3-4 18MM X_71453215 X_SMITH NEP,10142162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ3-4 18MM X_71453215 X_SMITH NEP,10142162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Maternal Screen Alpha Fetoprotein,10142195,CDM,0300,RC,82105,CPT,,,,,,outpatient,facility,,,70.00,21.00,15.93,70.0,,70.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.43,,,fee schedule,,,53.19,,,fee schedule,,,34.98,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,34.71,,,fee schedule,,,15.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.76,,,fee schedule,,,37.90,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,,,,,,,21.48,,,fee schedule,,,34.21,,,fee schedule,,,52.5,,,percent of total billed charges,,,16.43,,,fee schedule,,,15.93,,,fee schedule,,,16.76,,,fee schedule,,,25.26,,,fee schedule,,,16.43,,,fee schedule,,,52.5,,,percent of total billed charges,,,,,,,,,16.76,,,fee schedule,,,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,18.45,,,fee schedule,,,16.43,,,fee schedule,,,,,,,,,16.27,,,fee schedule,,,16.43,,,fee schedule,,,,,,,,,16.60,,,fee schedule,,,,,,,,
Maternal Screen Alpha Fetoprotein,10142195,CDM,0300,RC,82105,CPT,400,EAPG,,,,outpatient,facility,,,70.00,21.00,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM FEM ECLIPSE HIGH SZ8,10142278,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECLIPSE HIGH SZ8,10142278,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY PROPEL SMALL,10142279,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,715.00,214.50,277.42,607.75,,,,,,,,,,,,,,,,,,,,277.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.75,,,percent of total billed charges,,,321.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY PROPEL SMALL,10142279,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,715.00,214.50,303.88,607.75,,,,,,,,,,,,,service not payable,,,,,,,360.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,536.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,536.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,328.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSION CERVICAL 12X14X9 X_1000-00-0914 X_NU,10142280,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSION CERVICAL 12X14X9 X_1000-00-0914 X_NU,10142280,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BA400 4MM W/ABUTMENT 14MM,10142281,CDM,0278,RC,L8693,HCPCS,,,,,,inpatient,facility,,,9950.00,2985.00,3860.60,8457.5,,4875.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4179.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3860.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4228.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7462.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4975.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8457.5,,,percent of total billed charges,,,4477.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BA400 4MM W/ABUTMENT 14MM,10142281,CDM,0278,RC,L8693,HCPCS,,,,,,outpatient,facility,,,9950.00,2985.00,1312.17,8457.5,,4875.5,,,percent of total billed charges,,Paid in addition to outpatient services ,1792.44,,,fee schedule,,,4179.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5018.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,3770.69,,,fee schedule,,,1312.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1828.29,,,fee schedule,,,4116.79,,,fee schedule,,,,,,,,,1792.44,,,fee schedule,,,,,,,,,4228.75,,,percent of total billed charges,,Paid in addition to outpatient services ,3716.04,,,fee schedule,,,7462.5,,,percent of total billed charges,,,1792.44,,,fee schedule,,,1312.17,,,fee schedule,,,1828.29,,,fee schedule,,,4975.0,,,percent of total billed charges,,Paid in addition to outpatient services ,1792.44,,,fee schedule,,,7462.5,,,percent of total billed charges,,,1312.17,,,fee schedule,,,1828.29,,,fee schedule,,,,,,,,,8457.5,,,percent of total billed charges,,,4577.0,,,percent of total billed charges,,,,,,,,,,,,,,,1792.44,,,fee schedule,,,,,,,,,,,,,,,1792.44,,,fee schedule,,,,,,,,,1810.37,,,fee schedule,,,,,,,,
LENS TECNIS TORIC 20.5 X_ZCT150-20.5 X_PRECISION L,10142283,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC 20.5 X_ZCT150-20.5 X_PRECISION L,10142283,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ACTIS DUOFIX SZ10,10142388,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ACTIS DUOFIX SZ10,10142388,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DOME TALAR SULCUS INBONEII SZ1,10142389,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16048.00,4814.40,6226.62,13640.80,,7863.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6740.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6226.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6820.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12036.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8024.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13640.80,,,percent of total billed charges,,,7221.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOME TALAR SULCUS INBONEII SZ1,10142389,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16048.00,4814.40,6740.16,13640.80,,7863.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6740.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8094.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6820.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12036.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8024.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12036.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13640.80,,,percent of total billed charges,,,7382.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT INFINITY POLY SZ1 6MM X_33651106 X_WRIGHT M,10142390,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT INFINITY POLY SZ1 6MM X_33651106 X_WRIGHT M,10142390,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ARMADA 8.5X35MM X_8458535 X_NUVASIVE,10142391,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ARMADA 8.5X35MM X_8458535 X_NUVASIVE,10142391,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FILLER HOLE 4.5MM SCREW X_74800603 X_SMITH NEPHEW,10142392,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,535.00,160.50,207.58,454.75,,,,,,,,,,,,,,,,,,,,207.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,401.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.75,,,percent of total billed charges,,,240.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FILLER HOLE 4.5MM SCREW X_74800603 X_SMITH NEPHEW,10142392,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,535.00,160.50,227.38,454.75,,,,,,,,,,,,,service not payable,,,,,,,269.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,227.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,401.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,267.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,401.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,454.75,,,percent of total billed charges,,,246.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE INLINE CERTAS PLUS,10142394,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,15920.00,4776.00,6176.96,13532.0,,7800.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6686.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6176.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6766.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11940.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7960.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13532.0,,,percent of total billed charges,,,7164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE INLINE CERTAS PLUS,10142394,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,15920.00,4776.00,6686.40,13532.0,,7800.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6686.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8030.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6766.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11940.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7960.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11940.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13532.0,,,percent of total billed charges,,,7323.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUMP 700 CX 21CMX12CM,10142486,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,32474.00,9742.20,12599.91,27602.90,,15912.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13639.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12599.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13801.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16237.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27602.90,,,percent of total billed charges,,,14613.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUMP 700 CX 21CMX12CM,10142486,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,32474.00,9742.20,13639.08,27602.90,,15912.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13639.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16379.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13801.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24355.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16237.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24355.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27602.90,,,percent of total billed charges,,,14938.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 6FR 60X75CM,10142487,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ARTHRECTOMY SHEATH 1.25MMX145CM X_DBP-125MICR,10142488,CDM,0272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,11131.00,3339.30,4730.68,9461.35,,6878.96,,,percent of total billed charges,,,,,,,,service not payable,5431.93,,,percent of total billed charges,,,5614.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4730.68,,,percent of total billed charges,,,,,,,,,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5565.5,,,percent of total billed charges,,,,,,,,service not payable,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9461.35,,,percent of total billed charges,,,5120.26,,,percent of total billed charges,,,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER SPIKED 18MM X_AR-1349L X_ARTHREX INC,10142489,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SPIKED 18MM X_AR-1349L X_ARTHREX INC,10142489,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DYNANITE 11X10MM,10142490,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYNANITE 11X10MM,10142490,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG STR 6H X_AR-8943C-06 X_ARTHREX INC,10142491,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG STR 6H X_AR-8943C-06 X_ARTHREX INC,10142491,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COFLEX SPACER SZ14MM X_UQI00014 X_PARADIGM SPINE,10142492,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,20325.00,6097.50,7886.10,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7886.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17276.25,,,percent of total billed charges,,,9146.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COFLEX SPACER SZ14MM X_UQI00014 X_PARADIGM SPINE,10142492,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,20325.00,6097.50,8536.5,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10251.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17276.25,,,percent of total billed charges,,,9349.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AMPLIA MRI QUAD DF1,10142493,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,36475.00,10942.50,14152.30,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,14152.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31003.75,,,percent of total billed charges,,,16413.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AMPLIA MRI QUAD DF1,10142493,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,36475.00,10942.50,15319.5,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,18397.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31003.75,,,percent of total billed charges,,,16778.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT FOAM STRP BIO 25X50X4MM X_2102-1505 X_STRYKE,10142494,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5480.00,1644.00,2126.24,4658.0,,2685.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2301.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2126.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2329.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4110.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2740.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4658.0,,,percent of total billed charges,,,2466.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FOAM STRP BIO 25X50X4MM X_2102-1505 X_STRYKE,10142494,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5480.00,1644.00,2301.60,4658.0,,2685.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2301.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2764.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2329.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4110.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2740.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4110.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4658.0,,,percent of total billed charges,,,2520.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 12X14X8MM 7D X_1000-00-0814 X_NUVASIVE,10142495,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 12X14X8MM 7D X_1000-00-0814 X_NUVASIVE,10142495,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HELIX-R 66MM X_7800366 X_NUVASIVE,10142496,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2872.00,861.60,1114.34,2441.20,,,,,,,,,,,,,,,,,,,,1114.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1220.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2154.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1436.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2441.20,,,percent of total billed charges,,,1292.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HELIX-R 66MM X_7800366 X_NUVASIVE,10142496,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2872.00,861.60,1220.60,2441.20,,,,,,,,,,,,,service not payable,,,,,,,1448.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1220.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2154.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1436.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2154.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2441.20,,,percent of total billed charges,,,1321.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HELIX-R ST 4.5X17MM X_7805117 X_NUVASIVE,10142497,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,482.00,144.60,187.02,409.70,,,,,,,,,,,,,,,,,,,,187.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.70,,,percent of total billed charges,,,216.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HELIX-R ST 4.5X17MM X_7805117 X_NUVASIVE,10142497,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,482.00,144.60,204.85,409.70,,,,,,,,,,,,,service not payable,,,,,,,243.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,204.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,361.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,241.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,361.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,409.70,,,percent of total billed charges,,,221.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HELIX VAR SD 4.0X17MM,10142498,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,482.00,144.60,187.02,409.70,,,,,,,,,,,,,,,,,,,,187.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.70,,,percent of total billed charges,,,216.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HELIX VAR SD 4.0X17MM,10142498,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,482.00,144.60,204.85,409.70,,,,,,,,,,,,,service not payable,,,,,,,243.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,204.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,361.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,241.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,361.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,409.70,,,percent of total billed charges,,,221.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ARTHRECTOMY SHEATH 1.5MMX145CM X_DBP-150SOLID,10142499,CDM,0272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,11131.00,3339.30,4730.68,9461.35,,6878.96,,,percent of total billed charges,,,,,,,,service not payable,5431.93,,,percent of total billed charges,,,5614.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4730.68,,,percent of total billed charges,,,,,,,,,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5565.5,,,percent of total billed charges,,,,,,,,service not payable,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9461.35,,,percent of total billed charges,,,5120.26,,,percent of total billed charges,,,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ARTHRECTOMY SHEATH 1.25MMX60CM X_DBP-125SOLID,10142500,CDM,0272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,11131.00,3339.30,4730.68,9461.35,,6878.96,,,percent of total billed charges,,,,,,,,service not payable,5431.93,,,percent of total billed charges,,,5614.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4730.68,,,percent of total billed charges,,,,,,,,,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5565.5,,,percent of total billed charges,,,,,,,,service not payable,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9461.35,,,percent of total billed charges,,,5120.26,,,percent of total billed charges,,,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ARTHRECTOMY SHEATH 1.25MMX60CM X_DBP-125MICRO,10142501,CDM,0272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,11131.00,3339.30,4730.68,9461.35,,6878.96,,,percent of total billed charges,,,,,,,,service not payable,5431.93,,,percent of total billed charges,,,5614.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4730.68,,,percent of total billed charges,,,,,,,,,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5565.5,,,percent of total billed charges,,,,,,,,service not payable,8348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9461.35,,,percent of total billed charges,,,5120.26,,,percent of total billed charges,,,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7235.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI FL TD 7Z100MM X_71190100 X_SMITH NEP,10142503,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1124.00,337.20,436.11,955.40,,,,,,,,,,,,,,,,,,,,436.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,955.40,,,percent of total billed charges,,,505.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI FL TD 7Z100MM X_71190100 X_SMITH NEP,10142503,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1124.00,337.20,477.70,955.40,,,,,,,,,,,,,service not payable,,,,,,,566.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,955.40,,,percent of total billed charges,,,517.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Chg Arterial Draw,10146128,CDM,0300,RC,36600,CPT,,,,,,outpatient,facility,,,87.00,26.10,19.19,73.95,,53.77,,,percent of total billed charges,,,,,,,,,42.46,,,percent of total billed charges,,,53.97,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.19,,,fee schedule,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.57,,,fee schedule,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Chg Arterial Draw,10146128,CDM,0300,RC,36600,CPT,05734,APC,,,,outpatient,facility,,,87.00,26.10,87.0,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,87.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,87.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Chg Arterial Draw,10146128,CDM,0300,RC,36600,CPT,494,EAPG,,,,outpatient,facility,,,87.00,26.10,87.0,553.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,470.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,87.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,87.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,354.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,390.10,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CORT LAG 3.2X22MM X_LAG3.2-22 X_TRI-MED INC,10148111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LAG 3.2X22MM X_LAG3.2-22 X_TRI-MED INC,10148111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TWIST OFF 1.2X12MM,10148112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1610.00,483.00,624.68,1368.5,,,,,,,,,,,,,,,,,,,,624.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1207.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,805.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1368.5,,,percent of total billed charges,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TWIST OFF 1.2X12MM,10148112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1610.00,483.00,684.25,1368.5,,,,,,,,,,,,,service not payable,,,,,,,812.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,684.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1207.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,805.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1207.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1368.5,,,percent of total billed charges,,,740.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE STRAFIX 2X2MM,10148113,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE STRAFIX 2X2MM,10148113,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LP TI 3X24MM,10148116,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LP TI 3X24MM,10148116,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CL ECLIPSE SZ 5,10148117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CL ECLIPSE SZ 5,10148117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT TIBIAL CONE SZ8 X_5549-A-120 X_STRYKER ORT,10148118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13148.00,3944.40,5101.42,11175.80,,6442.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5522.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5101.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5587.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11175.80,,,percent of total billed charges,,,5916.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT TIBIAL CONE SZ8 X_5549-A-120 X_STRYKER ORT,10148118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13148.00,3944.40,5522.16,11175.80,,6442.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5522.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6631.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5587.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11175.80,,,percent of total billed charges,,,6048.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT TIBIAL SZ8 5MM X_5545-A-802 X_STRYKER ORTH,10148119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3397.00,1019.10,1318.04,2887.45,,,,,,,,,,,,,,,,,,,,1318.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1443.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1698.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2887.45,,,percent of total billed charges,,,1528.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT TIBIAL SZ8 5MM X_5545-A-802 X_STRYKER ORTH,10148119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3397.00,1019.10,1443.72,2887.45,,,,,,,,,,,,,service not payable,,,,,,,1713.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1443.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2547.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1698.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2887.45,,,percent of total billed charges,,,1562.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT F-D 10MM SZ8 RT,10148120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT F-D 10MM SZ8 RT,10148120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT F-P 10MM SZ8,10148121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT F-P 10MM SZ8,10148121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM STD COLLAR SZ 6,10148122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM STD COLLAR SZ 6,10148122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER PERCEPTA MRI CRT P,10148123,CDM,0278,RC,C2621,HCPCS,,,,,,inpatient,facility,,,19246.00,5773.80,7467.45,16359.1,,9430.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8083.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7467.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8179.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14434.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9623.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16359.1,,,percent of total billed charges,,,8660.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER PERCEPTA MRI CRT P,10148123,CDM,0278,RC,C2621,HCPCS,,,,,,outpatient,facility,,,19246.00,5773.80,8083.32,16359.1,,9430.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8083.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9707.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8179.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14434.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9623.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14434.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16359.1,,,percent of total billed charges,,,8853.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD GLBL UNITE 52X15MM STD,10148124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLBL UNITE 52X15MM STD,10148124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4X35MM X_AR-8840C-35 X_ARTHREX INC,10148125,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4X35MM X_AR-8840C-35 X_ARTHREX INC,10148125,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB DIST LCKG 6H 104MM,10148126,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB DIST LCKG 6H 104MM,10148126,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4X32MM X_873-132 X_MEDTRONIC,10148127,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2054.00,616.20,796.95,1745.90,,,,,,,,,,,,,,,,,,,,796.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,872.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1540.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1027.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1745.90,,,percent of total billed charges,,,924.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4X32MM X_873-132 X_MEDTRONIC,10148127,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2054.00,616.20,872.95,1745.90,,,,,,,,,,,,,service not payable,,,,,,,1036.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,872.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1540.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1027.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1540.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1745.90,,,percent of total billed charges,,,944.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANN TI 3.5 X 16MM,10148128,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN TI 3.5 X 16MM,10148128,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDE SURFACE T2/2 12MM X_NN221 X_AESCULAP IMPLANT,10148129,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDE SURFACE T2/2 12MM X_NN221 X_AESCULAP IMPLANT,10148129,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER KIT MIC G 16F (1),10148133,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,1151.00,345.30,489.18,978.35,,711.32,,,percent of total billed charges,,,,,,,,service not payable,561.69,,,percent of total billed charges,,,580.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,489.18,,,percent of total billed charges,,,,,,,,,863.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,575.5,,,percent of total billed charges,,,,,,,,service not payable,863.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,978.35,,,percent of total billed charges,,,529.46,,,percent of total billed charges,,,,,,,,,748.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,748.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS CL 13X6MM 20.5 DIO X_PCB00-20.5 X_PREC,10148134,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS CL 13X6MM 20.5 DIO X_PCB00-20.5 X_PREC,10148134,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS CL 13X6MM 25 DIO,10148135,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS CL 13X6MM 25 DIO,10148135,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS CL 13X6MM 18 DIO,10148136,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS CL 13X6MM 18 DIO,10148136,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANN MINI 20X3.0MM,10150096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1951.00,585.30,756.99,1658.35,,,,,,,,,,,,,,,,,,,,756.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.35,,,percent of total billed charges,,,877.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANN MINI 20X3.0MM,10150096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1951.00,585.30,829.17,1658.35,,,,,,,,,,,,,service not payable,,,,,,,984.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,829.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1463.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1463.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1658.35,,,percent of total billed charges,,,897.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECLIPSE HIGH SZ9,10150097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECLIPSE HIGH SZ9,10150097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FIBULOCK LT 3.0X130MM X_FIB30130L X_ARTHREX I,10150098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FIBULOCK LT 3.0X130MM X_FIB30130L X_ARTHREX I,10150098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORTEX 2.7X12MM X_AR-8827-12 X_ARTHREX IN,10150099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORTEX 2.7X12MM X_AR-8827-12 X_ARTHREX IN,10150099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACK PROCEDURE FIBULOCK NAIL X_ST6100 X_ARTHREX IN,10150100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACK PROCEDURE FIBULOCK NAIL X_ST6100 X_ARTHREX IN,10150100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE AEQUALIS 220MM,10150101,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,749.00,224.70,318.32,636.65,,462.88,,,percent of total billed charges,,,,,,,,service not payable,365.51,,,percent of total billed charges,,,377.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,318.32,,,percent of total billed charges,,,,,,,,,561.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,374.5,,,percent of total billed charges,,,,,,,,service not payable,561.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,344.54,,,percent of total billed charges,,,,,,,,,486.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,486.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE GLENOID 25MM 15DEG P,10150102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11145.00,3343.50,4324.26,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9473.25,,,percent of total billed charges,,,5015.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE GLENOID 25MM 15DEG P,10150102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11145.00,3343.50,4680.90,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5621.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9473.25,,,percent of total billed charges,,,5126.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID 39MM PERFORM REV,10150103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8395.00,2518.50,3257.26,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3257.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7135.75,,,percent of total billed charges,,,3777.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID 39MM PERFORM REV,10150103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8395.00,2518.50,3525.90,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4234.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7135.75,,,percent of total billed charges,,,3861.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT HUM AQLS 39X6X12.5MM,10150104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4384.00,1315.20,1700.99,3726.40,,,,,,,,,,,,,,,,,,,,1700.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1863.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3726.40,,,percent of total billed charges,,,1972.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT HUM AQLS 39X6X12.5MM,10150104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4384.00,1315.20,1863.2,3726.40,,,,,,,,,,,,,service not payable,,,,,,,2211.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1863.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3726.40,,,percent of total billed charges,,,2016.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
POST SHOULDER GLENOID 6.5X25MM,10150105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POST SHOULDER GLENOID 6.5X25MM,10150105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 22MM PERFORM P,10150106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1354.00,406.20,525.35,1150.90,,,,,,,,,,,,,,,,,,,,525.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1015.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.90,,,percent of total billed charges,,,609.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 22MM PERFORM P,10150106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1354.00,406.20,575.45,1150.90,,,,,,,,,,,,,service not payable,,,,,,,682.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,575.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1015.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,677.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1015.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1150.90,,,percent of total billed charges,,,622.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 30MM PERFORM P,10150107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,677.00,203.10,262.68,575.45,,,,,,,,,,,,,,,,,,,,262.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.45,,,percent of total billed charges,,,304.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 30MM PERFORM P,10150107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,677.00,203.10,287.72,575.45,,,,,,,,,,,,,service not payable,,,,,,,341.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,507.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,575.45,,,percent of total billed charges,,,311.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 34MM PERFORM P,10150108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,677.00,203.10,262.68,575.45,,,,,,,,,,,,,,,,,,,,262.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.45,,,percent of total billed charges,,,304.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 34MM PERFORM P,10150108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,677.00,203.10,287.72,575.45,,,,,,,,,,,,,service not payable,,,,,,,341.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,507.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,575.45,,,percent of total billed charges,,,311.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 6X13MM 10.0T,10150109,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2163.00,648.90,839.24,1838.55,,,,,,,,,,,,,,,,,,,,839.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1838.55,,,percent of total billed charges,,,973.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 6X13MM 10.0T,10150109,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,,,,,,,,,,,,service not payable,,,,,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM VIGILANT CRT-D,10150110,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,37481.00,11244.30,14542.63,31858.85,,18365.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15742.02,,,percent of total billed charges,,Paid in addition to inpatient services ,14542.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15929.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28110.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18740.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31858.85,,,percent of total billed charges,,,16866.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM VIGILANT CRT-D,10150110,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,37481.00,11244.30,15742.02,31858.85,,18365.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15742.02,,,percent of total billed charges,,Paid in addition to outpatient services ,18905.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15929.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28110.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18740.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28110.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31858.85,,,percent of total billed charges,,,17241.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE TIB PLATEAU MOD SZ1 X_NN071Z X_AESCULAP,10150112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE TIB PLATEAU MOD SZ1 X_NN071Z X_AESCULAP,10150112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE TIB MOD SZ1/1 12MM X_NN211 X_AESCULAP,10150113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE TIB MOD SZ1/1 12MM X_NN211 X_AESCULAP,10150113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE PIN 3.2X343MM X_71674130 X_SMITH NEPHEW,10150115,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,587.00,176.10,227.76,498.95,,,,,,,,,,,,,,,,,,,,227.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,440.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.95,,,percent of total billed charges,,,264.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE PIN 3.2X343MM X_71674130 X_SMITH NEPHEW,10150115,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,587.00,176.10,249.47,498.95,,,,,,,,,,,,,service not payable,,,,,,,296.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,440.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,440.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.95,,,percent of total billed charges,,,270.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Blastomyces Ab with Reflex,10150118,CDM,0300,RC,86612,CPT,,,,,,outpatient,facility,,,72.00,21.60,12.26,61.20,,24.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.64,,,fee schedule,,,18.57,,,fee schedule,,,26.91,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.70,,,fee schedule,,,12.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.89,,,fee schedule,,,29.15,,,fee schedule,,,,,,,,,12.64,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.32,,,fee schedule,,,54.0,,,percent of total billed charges,,,12.64,,,fee schedule,,,12.26,,,fee schedule,,,12.89,,,fee schedule,,,19.32,,,fee schedule,,,12.64,,,fee schedule,,,54.0,,,percent of total billed charges,,,,,,,,,12.89,,,fee schedule,,,,,,,,,61.20,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,14.19,,,fee schedule,,,12.64,,,fee schedule,,,,,,,,,12.51,,,fee schedule,,,12.64,,,fee schedule,,,,,,,,,12.77,,,fee schedule,,,,,,,,
Blastomyces Ab with Reflex,10150118,CDM,0300,RC,86612,CPT,394,EAPG,,,,outpatient,facility,,,72.00,21.60,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
REFLEX ONLY Blastomyces dermatitidis Ab by Id 0050,10150119,CDM,0300,RC,86612,CPT,,,,,,outpatient,facility,,,15.00,4.50,6.90,29.15,,15.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.64,,,fee schedule,,,15.0,,,fee schedule,,,26.91,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.70,,,fee schedule,,,12.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.89,,,fee schedule,,,29.15,,,fee schedule,,,,,,,,,12.64,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.32,,,fee schedule,,,11.25,,,percent of total billed charges,,,12.64,,,fee schedule,,,12.26,,,fee schedule,,,12.89,,,fee schedule,,,19.32,,,fee schedule,,,12.64,,,fee schedule,,,11.25,,,percent of total billed charges,,,,,,,,,12.89,,,fee schedule,,,,,,,,,12.75,,,percent of total billed charges,,,6.90,,,percent of total billed charges,,,,,,,,,14.19,,,fee schedule,,,12.64,,,fee schedule,,,,,,,,,12.51,,,fee schedule,,,12.64,,,fee schedule,,,,,,,,,12.77,,,fee schedule,,,,,,,,
REFLEX ONLY Blastomyces dermatitidis Ab by Id 0050,10150119,CDM,0300,RC,86612,CPT,394,EAPG,,,,outpatient,facility,,,15.00,4.50,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE HUM PROX LAT 12H RT X_627242 X_STRYKER ORTHO,10150484,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9095.00,2728.50,3528.86,7730.75,,4456.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3819.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3528.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3865.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6821.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4547.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7730.75,,,percent of total billed charges,,,4092.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM PROX LAT 12H RT X_627242 X_STRYKER ORTHO,10150484,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9095.00,2728.50,3819.90,7730.75,,4456.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3819.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4587.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3865.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6821.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4547.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6821.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7730.75,,,percent of total billed charges,,,4183.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FT 4.0X22MM X_607322 X_STRYKER ORTHOPAEDICS,10150485,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT 4.0X22MM X_607322 X_STRYKER ORTHOPAEDICS,10150485,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PT 4.0X34MM X_607434 X_STRYKER ORTHOPAEDICS,10150486,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PT 4.0X34MM X_607434 X_STRYKER ORTHOPAEDICS,10150486,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PT 4.0X50MM X_607450 X_STRYKER ORTHOPAEDICS,10150487,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PT 4.0X50MM X_607450 X_STRYKER ORTHOPAEDICS,10150487,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST 3.5X22MM X_661422 X_STRYKER ORTHOPAEDICS,10150488,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,196.00,58.80,76.05,166.60,,,,,,,,,,,,,,,,,,,,76.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.60,,,percent of total billed charges,,,88.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST 3.5X22MM X_661422 X_STRYKER ORTHOPAEDICS,10150488,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,196.00,58.80,83.30,166.60,,,,,,,,,,,,,service not payable,,,,,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6MMX15CM VASC XRAY 120CM,10150489,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13080.00,3924.00,5075.04,11118.0,,6409.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5493.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5075.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9810.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6540.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11118.0,,,percent of total billed charges,,,5886.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6MMX15CM VASC XRAY 120CM,10150489,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13080.00,3924.00,5493.60,11118.0,,6409.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5493.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6597.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5559.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9810.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6540.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9810.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11118.0,,,percent of total billed charges,,,6016.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DILAT 35LP PTA5 80 5X4,10150490,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ELECTRODE EMBLEM S-ICD,10150491,CDM,0278,RC,C1896,HCPCS,,,,,,inpatient,facility,,,14458.00,4337.40,5609.70,12289.30,,7084.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6072.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5609.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6144.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10843.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12289.30,,,percent of total billed charges,,,6506.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE EMBLEM S-ICD,10150491,CDM,0278,RC,C1896,HCPCS,,,,,,outpatient,facility,,,14458.00,4337.40,6072.36,12289.30,,7084.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6072.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7292.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6144.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10843.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10843.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12289.30,,,percent of total billed charges,,,6650.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATCH RPR PERI GUARD 10X16CM,10150494,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3442.00,1032.60,1335.50,2925.70,,,,,,,,,,,,,,,,,,,,1335.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1462.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2581.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2925.70,,,percent of total billed charges,,,1548.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATCH RPR PERI GUARD 10X16CM,10150494,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3442.00,1032.60,1462.85,2925.70,,,,,,,,,,,,,service not payable,,,,,,,1736.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1462.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2581.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1721.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2581.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2925.70,,,percent of total billed charges,,,1583.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SOF-CURL URETERAL 6FRX20CM X_SSC6020 X_OLYMP,10150495,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,385.00,115.50,149.38,327.25,,,,,,,,,,,,,,,,,,,,149.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.25,,,percent of total billed charges,,,173.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SOF-CURL URETERAL 6FRX20CM X_SSC6020 X_OLYMP,10150495,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,385.00,115.50,163.62,327.25,,,,,,,,,,,,,service not payable,,,,,,,194.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,327.25,,,percent of total billed charges,,,177.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE TIB PLATEAU X_NN072Z X_AESCULAP IMPLANTS,10150496,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE TIB PLATEAU X_NN072Z X_AESCULAP IMPLANTS,10150496,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD W/NECK FEMORAL X_LET17009889-007 X_ALAMO TISS,10150497,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD W/NECK FEMORAL X_LET17009889-007 X_ALAMO TISS,10150497,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE FEM FR4 8FR 100CM,10150498,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE FEM RT FR4 8FR 90CM,10150499,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE FEM FR4SH 8FR 100CM,10150500,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OP Estab - In Depth,10152221,CDM,0510,RC,99214,CPT,,,,,,outpatient,facility,,,384.00,115.20,176.64,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OP Estab - In Depth,10152221,CDM,0510,RC,99214,CPT,852,EAPG,,,,outpatient,facility,,,384.00,115.20,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OP Estab - In Depth,10152221,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,87.86,162.35,,118.04,,,percent of total billed charges,,,,,,,,,93.21,,,percent of total billed charges,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,124.15,,,percent of total billed charges,,,,,,,,,,,,,,,124.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
OP Estab - In Depth,10152221,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,191.00,57.30,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
OP Estab - In Depth,10152221,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,191.00,57.30,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OP Estab - In Depth,10152222,CDM,0510,RC,99214,CPT,,,,,,outpatient,facility,,,384.00,115.20,176.64,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OP Estab - In Depth,10152222,CDM,0510,RC,99214,CPT,852,EAPG,,,,outpatient,facility,,,384.00,115.20,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OP Estab - In Depth,10152222,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,318.00,95.40,146.28,270.30,,196.52,,,percent of total billed charges,,,,,,,,,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
OP Estab - In Depth,10152222,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,318.00,95.40,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
OP Estab - In Depth,10152222,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,318.00,95.40,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Aspergillus Antibody (CF),10152290,CDM,0300,RC,86606,CPT,,,,,,outpatient,facility,,,27.00,8.10,12.42,34.01,,27.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.75,,,fee schedule,,,27.0,,,fee schedule,,,31.39,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,31.15,,,fee schedule,,,14.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",15.04,,,fee schedule,,,34.01,,,fee schedule,,,,,,,,,14.75,,,fee schedule,,,,,,,,,19.38,,,fee schedule,,,30.70,,,fee schedule,,,20.25,,,percent of total billed charges,,,14.75,,,fee schedule,,,14.30,,,fee schedule,,,15.04,,,fee schedule,,,22.79,,,fee schedule,,,14.75,,,fee schedule,,,20.25,,,percent of total billed charges,,,,,,,,,15.04,,,fee schedule,,,,,,,,,22.95,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,,,,,,,16.56,,,fee schedule,,,14.75,,,fee schedule,,,,,,,,,14.6,,,fee schedule,,,14.75,,,fee schedule,,,,,,,,,14.9,,,fee schedule,,,,,,,,
Aspergillus Antibody (CF),10152290,CDM,0300,RC,86606,CPT,394,EAPG,,,,outpatient,facility,,,27.00,8.10,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Histoplasma Mycelia,10152291,CDM,0300,RC,86698,CPT,,,,,,outpatient,facility,,,23.00,6.90,10.58,31.17,,23.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.51,,,fee schedule,,,23.0,,,fee schedule,,,28.76,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.55,,,fee schedule,,,13.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.78,,,fee schedule,,,31.17,,,fee schedule,,,,,,,,,13.51,,,fee schedule,,,,,,,,,17.69,,,fee schedule,,,28.13,,,fee schedule,,,17.25,,,percent of total billed charges,,,13.51,,,fee schedule,,,13.1,,,fee schedule,,,13.78,,,fee schedule,,,20.81,,,fee schedule,,,13.51,,,fee schedule,,,17.25,,,percent of total billed charges,,,,,,,,,13.78,,,fee schedule,,,,,,,,,19.55,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,,,,,,,15.17,,,fee schedule,,,13.51,,,fee schedule,,,,,,,,,13.38,,,fee schedule,,,13.51,,,fee schedule,,,,,,,,,13.65,,,fee schedule,,,,,,,,
Histoplasma Mycelia,10152291,CDM,0300,RC,86698,CPT,394,EAPG,,,,outpatient,facility,,,23.00,6.90,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Histoplasma Yeast,10152292,CDM,0300,RC,86698,CPT,,,,,,outpatient,facility,,,23.00,6.90,10.58,31.17,,23.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.51,,,fee schedule,,,23.0,,,fee schedule,,,28.76,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.55,,,fee schedule,,,13.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.78,,,fee schedule,,,31.17,,,fee schedule,,,,,,,,,13.51,,,fee schedule,,,,,,,,,17.69,,,fee schedule,,,28.13,,,fee schedule,,,17.25,,,percent of total billed charges,,,13.51,,,fee schedule,,,13.1,,,fee schedule,,,13.78,,,fee schedule,,,20.81,,,fee schedule,,,13.51,,,fee schedule,,,17.25,,,percent of total billed charges,,,,,,,,,13.78,,,fee schedule,,,,,,,,,19.55,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,,,,,,,15.17,,,fee schedule,,,13.51,,,fee schedule,,,,,,,,,13.38,,,fee schedule,,,13.51,,,fee schedule,,,,,,,,,13.65,,,fee schedule,,,,,,,,
Histoplasma Yeast,10152292,CDM,0300,RC,86698,CPT,394,EAPG,,,,outpatient,facility,,,23.00,6.90,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Coccidioides Antibody CF,10152293,CDM,0300,RC,86635,CPT,,,,,,outpatient,facility,,,21.00,6.30,9.66,25.92,,21.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.24,,,fee schedule,,,18.57,,,fee schedule,,,23.92,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,23.74,,,fee schedule,,,10.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.46,,,fee schedule,,,25.92,,,fee schedule,,,,,,,,,11.24,,,fee schedule,,,,,,,,,14.75,,,fee schedule,,,23.40,,,fee schedule,,,15.75,,,percent of total billed charges,,,11.24,,,fee schedule,,,10.9,,,fee schedule,,,11.46,,,fee schedule,,,17.34,,,fee schedule,,,11.24,,,fee schedule,,,15.75,,,percent of total billed charges,,,,,,,,,11.46,,,fee schedule,,,,,,,,,17.85,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,,,,,,,12.62,,,fee schedule,,,11.24,,,fee schedule,,,,,,,,,11.13,,,fee schedule,,,11.24,,,fee schedule,,,,,,,,,11.35,,,fee schedule,,,,,,,,
Coccidioides Antibody CF,10152293,CDM,0300,RC,86635,CPT,394,EAPG,,,,outpatient,facility,,,21.00,6.30,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Blastomyces Ab (EIA),10152294,CDM,0300,RC,86612,CPT,,,,,,outpatient,facility,,,24.00,7.20,11.04,29.15,,24.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.64,,,fee schedule,,,18.57,,,fee schedule,,,26.91,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.70,,,fee schedule,,,12.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.89,,,fee schedule,,,29.15,,,fee schedule,,,,,,,,,12.64,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.32,,,fee schedule,,,18.0,,,percent of total billed charges,,,12.64,,,fee schedule,,,12.26,,,fee schedule,,,12.89,,,fee schedule,,,19.32,,,fee schedule,,,12.64,,,fee schedule,,,18.0,,,percent of total billed charges,,,,,,,,,12.89,,,fee schedule,,,,,,,,,20.40,,,percent of total billed charges,,,11.04,,,percent of total billed charges,,,,,,,,,14.19,,,fee schedule,,,12.64,,,fee schedule,,,,,,,,,12.51,,,fee schedule,,,12.64,,,fee schedule,,,,,,,,,12.77,,,fee schedule,,,,,,,,
Blastomyces Ab (EIA),10152294,CDM,0300,RC,86612,CPT,394,EAPG,,,,outpatient,facility,,,24.00,7.20,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Occult Blood Gastric Fluid - MH/WH/JE,10152295,CDM,0300,RC,82271,CPT,,,,,,outpatient,facility,,,91.00,27.30,5.05,77.35,,11.58,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.21,,,fee schedule,,,8.64,,,fee schedule,,,11.1,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.01,,,fee schedule,,,5.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.31,,,fee schedule,,,12.02,,,fee schedule,,,,,,,,,5.21,,,fee schedule,,,,,,,,,6.73,,,fee schedule,,,10.85,,,fee schedule,,,68.25,,,percent of total billed charges,,,5.21,,,fee schedule,,,5.05,,,fee schedule,,,5.31,,,fee schedule,,,7.92,,,fee schedule,,,5.21,,,fee schedule,,,68.25,,,percent of total billed charges,,,,,,,,,5.31,,,fee schedule,,,,,,,,,77.35,,,percent of total billed charges,,,41.86,,,percent of total billed charges,,,,,,,,,5.85,,,fee schedule,,,5.21,,,fee schedule,,,,,,,,,5.16,,,fee schedule,,,5.21,,,fee schedule,,,,,,,,,5.26,,,fee schedule,,,,,,,,
Occult Blood Gastric Fluid - MH/WH/JE,10152295,CDM,0300,RC,82271,CPT,402,EAPG,,,,outpatient,facility,,,91.00,27.30,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Eosinophil Smear,10152298,CDM,0300,RC,89190,CPT,,,,,,outpatient,facility,,,52.00,15.60,5.5,44.20,,20.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.67,,,fee schedule,,,15.05,,,fee schedule,,,12.08,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.99,,,fee schedule,,,5.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.78,,,fee schedule,,,13.09,,,fee schedule,,,,,,,,,5.67,,,fee schedule,,,,,,,,,7.58,,,fee schedule,,,11.81,,,fee schedule,,,39.0,,,percent of total billed charges,,,5.67,,,fee schedule,,,5.5,,,fee schedule,,,5.78,,,fee schedule,,,8.91,,,fee schedule,,,5.67,,,fee schedule,,,39.0,,,percent of total billed charges,,,,,,,,,5.78,,,fee schedule,,,,,,,,,44.20,,,percent of total billed charges,,,23.92,,,percent of total billed charges,,,,,,,,,6.37,,,fee schedule,,,5.67,,,fee schedule,,,,,,,,,5.62,,,fee schedule,,,5.67,,,fee schedule,,,,,,,,,5.73,,,fee schedule,,,,,,,,
Eosinophil Smear,10152298,CDM,0300,RC,89190,CPT,390,EAPG,,,,outpatient,facility,,,52.00,15.60,5.88,120.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,102.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.44,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STAPLE DYN NITI 18WX18L X_AR-8719DS-1818 X_ARTHREX,10156131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYN NITI 18WX18L X_AR-8719DS-1818 X_ARTHREX,10156131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP CANN FT 55X5MM LG,10156132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP CANN FT 55X5MM LG,10156132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE W/TRCR TIP .062X9.25,10156133,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,99.00,29.70,42.08,84.15,,61.18,,,percent of total billed charges,,,,,,,,service not payable,48.31,,,percent of total billed charges,,,49.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.08,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,74.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,64.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,64.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LO-PRO TI 4.0X16MM X_AR-8940-16 X_ARTHREX IN,10156134,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LO-PRO TI 4.0X16MM X_AR-8940-16 X_ARTHREX IN,10156134,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG THRD TUB TI 8H X_AR-9943T-08 X_ARTHREX,10156135,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG THRD TUB TI 8H X_AR-9943T-08 X_ARTHREX,10156135,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.82,1231.65,,,,,,,,,,,,,service not payable,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP END T2 PLUS 5MM 11.5MM,10156136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,836.00,250.80,324.37,710.60,,,,,,,,,,,,,,,,,,,,324.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,627.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,710.60,,,percent of total billed charges,,,376.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP END T2 PLUS 5MM 11.5MM,10156136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,836.00,250.80,355.30,710.60,,,,,,,,,,,,,service not payable,,,,,,,421.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,355.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,627.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,418.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,627.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,710.60,,,percent of total billed charges,,,384.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH PANEL SML GRID 84X53X.6MM X_25-005-10-09 X_KL,10156138,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2363.00,708.90,916.84,2008.55,,,,,,,,,,,,,,,,,,,,916.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1772.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1181.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2008.55,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH PANEL SML GRID 84X53X.6MM X_25-005-10-09 X_KL,10156138,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2363.00,708.90,1004.28,2008.55,,,,,,,,,,,,,service not payable,,,,,,,1191.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1004.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1772.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1181.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1772.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2008.55,,,percent of total billed charges,,,1086.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 5X70MM X_AR-8750-70H X_ARTHREX INC,10156139,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 5X70MM X_AR-8750-70H X_ARTHREX INC,10156139,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT 2.7X40MM X_7382-3040 X_SMITH NEPHEW,10156140,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,117.00,35.10,45.40,99.45,,,,,,,,,,,,,,,,,,,,45.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,87.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.45,,,percent of total billed charges,,,52.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT 2.7X40MM X_7382-3040 X_SMITH NEPHEW,10156140,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,117.00,35.10,49.73,99.45,,,,,,,,,,,,,service not payable,,,,,,,59.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,49.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,87.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,58.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,87.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,99.45,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER BIVENTRIC MRI CRT-D,10156141,CDM,0275,RC,C2619,HCPCS,,,,,,inpatient,facility,,,36475.00,10942.50,14152.30,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,14152.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31003.75,,,percent of total billed charges,,,16413.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER BIVENTRIC MRI CRT-D,10156141,CDM,0275,RC,C2619,HCPCS,,,,,,outpatient,facility,,,36475.00,10942.50,15319.5,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,18397.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31003.75,,,percent of total billed charges,,,16778.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FIXED LK 4.75X30MM,10156142,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FIXED LK 4.75X30MM,10156142,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 16MM,10156144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 16MM,10156144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 4FR 40X75CM,10156148,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 4FR 60X75CM,10156149,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 4FR 100X75CM,10156150,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 5FR 40X75CM,10156151,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 5FR 60X75CM,10156152,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 5FR 100X75CM,10156153,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 6FR 40X75CM,10156154,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 6FR 100X75CM,10156155,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 7FR 40X75CM,10156156,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 7FR 60X75CM,10156157,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 8FR 40X75CM,10156158,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 9FR 40X75CM,10156159,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 9FR 60X75CM,10156160,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 10FR 40X75CM,10156161,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLN LUTONIX 12FR 40X75CM,10156162,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPECTRA WAVEWRITER IPG KIT,10158105,CDM,0278,RC,C1820,HCPCS,,,,,,inpatient,facility,,,37809.00,11342.70,14669.89,32137.65,,18526.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15879.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14669.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16068.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28356.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18904.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32137.65,,,percent of total billed charges,,,17014.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPECTRA WAVEWRITER IPG KIT,10158105,CDM,0278,RC,C1820,HCPCS,,,,,,outpatient,facility,,,37809.00,11342.70,15879.78,32137.65,,18526.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15879.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19070.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16068.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28356.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18904.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28356.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32137.65,,,percent of total billed charges,,,17392.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS METACARPOPHAL LG,10158107,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10162.00,3048.60,3942.86,8637.70,,4979.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4268.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3942.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4318.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8637.70,,,percent of total billed charges,,,4572.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS METACARPOPHAL LG,10158107,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10162.00,3048.60,4268.04,8637.70,,4979.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4268.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4318.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Putty Graft Bone Allograft Demineralized Matrix Sy,10158108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Putty Graft Bone Allograft Demineralized Matrix Sy,10158108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cage Spine Lumbar Posterior Tritanium Titanium All,10158109,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10924.00,3277.20,4238.51,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4238.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9285.40,,,percent of total billed charges,,,4915.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Cage Spine Lumbar Posterior Tritanium Titanium All,10158109,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10924.00,3277.20,4588.08,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5510.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9285.40,,,percent of total billed charges,,,5025.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT BALL 8X39MM 135CM,10158110,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE POST-LATERAL HUM 5HR X_70-0375 X_ACUMED,10158111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4205.00,1261.50,1631.54,3574.25,,,,,,,,,,,,,,,,,,,,1631.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3574.25,,,percent of total billed charges,,,1892.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE POST-LATERAL HUM 5HR X_70-0375 X_ACUMED,10158111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4205.00,1261.50,1787.12,3574.25,,,,,,,,,,,,,service not payable,,,,,,,2121.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3574.25,,,percent of total billed charges,,,1934.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP RT 2.4-2.7X52MM,10158112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3322.00,996.60,1288.94,2823.70,,,,,,,,,,,,,,,,,,,,1288.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1411.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1661.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2823.70,,,percent of total billed charges,,,1494.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP RT 2.4-2.7X52MM,10158112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3322.00,996.60,1411.85,2823.70,,,,,,,,,,,,,service not payable,,,,,,,1675.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1411.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2491.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1661.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2491.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2823.70,,,percent of total billed charges,,,1528.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LK ST 2.7X10MM,10158113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,791.00,237.30,306.91,672.35,,,,,,,,,,,,,,,,,,,,306.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,593.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,395.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.35,,,percent of total billed charges,,,355.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LK ST 2.7X10MM,10158113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,791.00,237.30,336.18,672.35,,,,,,,,,,,,,service not payable,,,,,,,398.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,336.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,593.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,395.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,593.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,672.35,,,percent of total billed charges,,,363.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HINDFOOT 11.5MMX20CM X_71701120R X_SMITH NEPH,10158114,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6393.00,1917.90,2480.48,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.05,,,percent of total billed charges,,,2876.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HINDFOOT 11.5MMX20CM X_71701120R X_SMITH NEPH,10158114,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6393.00,1917.90,2685.06,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3224.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.05,,,percent of total billed charges,,,2940.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7X120MM X_71109120 X_SMITH NEPHEW,10158115,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1124.00,337.20,436.11,955.40,,,,,,,,,,,,,,,,,,,,436.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,955.40,,,percent of total billed charges,,,505.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7X120MM X_71109120 X_SMITH NEPHEW,10158115,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1124.00,337.20,477.70,955.40,,,,,,,,,,,,,service not payable,,,,,,,566.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,955.40,,,percent of total billed charges,,,517.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10X10 X_VBH101002A X_GORE MEDICAL,10158117,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,11703.00,3510.90,4540.76,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4540.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9947.55,,,percent of total billed charges,,,5266.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10X10 X_VBH101002A X_GORE MEDICAL,10158117,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4915.26,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LT 21MM,10158122,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,26007.00,7802.10,10090.72,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10090.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22105.95,,,percent of total billed charges,,,11703.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LT 21MM,10158122,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,26007.00,7802.10,10922.94,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13117.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22105.95,,,percent of total billed charges,,,11963.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LT 24MM,10158123,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,26007.00,7802.10,10090.72,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10090.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22105.95,,,percent of total billed charges,,,11703.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LT 24MM,10158123,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,26007.00,7802.10,10922.94,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13117.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22105.95,,,percent of total billed charges,,,11963.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LT 27MM,10158124,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,26007.00,7802.10,10090.72,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10090.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22105.95,,,percent of total billed charges,,,11703.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LT 27MM,10158124,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,26007.00,7802.10,10922.94,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13117.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22105.95,,,percent of total billed charges,,,11963.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LT 30MM,10158125,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,26007.00,7802.10,10090.72,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10090.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22105.95,,,percent of total billed charges,,,11703.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LT 30MM,10158125,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,26007.00,7802.10,10922.94,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13117.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22105.95,,,percent of total billed charges,,,11963.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LT 33MM,10158126,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,26007.00,7802.10,10090.72,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10090.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22105.95,,,percent of total billed charges,,,11703.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LT 33MM,10158126,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,26007.00,7802.10,10922.94,22105.95,,12743.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10922.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13117.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11052.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13003.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19505.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22105.95,,,percent of total billed charges,,,11963.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE XT DR MRI,10158130,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,12340.00,3702.00,4787.92,10489.0,,6046.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5182.80,,,percent of total billed charges,,Paid in addition to inpatient services ,4787.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5244.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9255.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6170.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10489.0,,,percent of total billed charges,,,5553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE XT DR MRI,10158130,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,12340.00,3702.00,5182.80,10489.0,,6046.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5182.80,,,percent of total billed charges,,Paid in addition to outpatient services ,6224.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5244.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9255.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6170.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9255.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10489.0,,,percent of total billed charges,,,5676.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE S DR MRI,10158131,CDM,0275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,11029.00,3308.70,4279.25,9374.65,,5404.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4632.18,,,percent of total billed charges,,Paid in addition to inpatient services ,4279.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4687.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8271.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5514.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9374.65,,,percent of total billed charges,,,4963.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE S DR MRI,10158131,CDM,0275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,11029.00,3308.70,4632.18,9374.65,,5404.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4632.18,,,percent of total billed charges,,Paid in addition to outpatient services ,5563.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4687.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8271.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5514.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8271.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9374.65,,,percent of total billed charges,,,5073.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE XT SR MRI,10158132,CDM,0275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,12340.00,3702.00,4787.92,10489.0,,6046.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5182.80,,,percent of total billed charges,,Paid in addition to inpatient services ,4787.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5244.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9255.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6170.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10489.0,,,percent of total billed charges,,,5553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE XT SR MRI,10158132,CDM,0275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,12340.00,3702.00,5182.80,10489.0,,6046.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5182.80,,,percent of total billed charges,,Paid in addition to outpatient services ,6224.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5244.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9255.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6170.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9255.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10489.0,,,percent of total billed charges,,,5676.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE S SR MRI,10158133,CDM,0278,RC,C1786,HCPCS,,,,,,inpatient,facility,,,11029.00,3308.70,4279.25,9374.65,,5404.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4632.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4279.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4687.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8271.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5514.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9374.65,,,percent of total billed charges,,,4963.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE S SR MRI,10158133,CDM,0278,RC,C1786,HCPCS,,,,,,outpatient,facility,,,11029.00,3308.70,4632.18,9374.65,,5404.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4632.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5563.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4687.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8271.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5514.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8271.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9374.65,,,percent of total billed charges,,,5073.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE XT DR MRI SYS X_AZUREXTDRMRIMEEM X,10158134,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,14864.00,4459.20,5767.23,12634.4,,7283.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6242.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5767.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6317.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11148.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12634.4,,,percent of total billed charges,,,6688.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE XT DR MRI SYS X_AZUREXTDRMRIMEEM X,10158134,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,14864.00,4459.20,6242.88,12634.4,,7283.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6242.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7497.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6317.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11148.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11148.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12634.4,,,percent of total billed charges,,,6837.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE XT SR MRI SYS X_AZURESDRMRIMEEM X_,10158135,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13553.00,4065.90,5258.56,11520.05,,6640.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5692.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5258.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5760.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10164.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6776.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11520.05,,,percent of total billed charges,,,6098.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE XT SR MRI SYS X_AZURESDRMRIMEEM X_,10158135,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13553.00,4065.90,5692.26,11520.05,,6640.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5692.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6836.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5760.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10164.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6776.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10164.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11520.05,,,percent of total billed charges,,,6234.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE XT SR MRI SYS X_AZUREXTSRMRIMEEM X,10158136,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,14864.00,4459.20,5767.23,12634.4,,7283.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6242.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5767.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6317.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11148.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12634.4,,,percent of total billed charges,,,6688.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE XT SR MRI SYS X_AZUREXTSRMRIMEEM X,10158136,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,14864.00,4459.20,6242.88,12634.4,,7283.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6242.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7497.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6317.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11148.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11148.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12634.4,,,percent of total billed charges,,,6837.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER AZURE S SR MRI SYS X_AZURESSRMRIMEEM X_M,10158137,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13553.00,4065.90,5258.56,11520.05,,6640.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5692.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5258.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5760.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10164.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6776.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11520.05,,,percent of total billed charges,,,6098.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER AZURE S SR MRI SYS X_AZURESSRMRIMEEM X_M,10158137,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13553.00,4065.90,5692.26,11520.05,,6640.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5692.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6836.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5760.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10164.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6776.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10164.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11520.05,,,percent of total billed charges,,,6234.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROCESSORS SOUND KIT N7 DUAL,10158138,CDM,0274,RC,L8627,HCPCS,,,,,,inpatient,facility,,,31034.00,9310.20,12041.19,26378.90,,15206.66,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13034.28,,,percent of total billed charges,,Paid in addition to inpatient services ,12041.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13189.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23275.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15517.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26378.90,,,percent of total billed charges,,,13965.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCESSORS SOUND KIT N7 DUAL,10158138,CDM,0274,RC,L8627,HCPCS,,,,,,outpatient,facility,,,31034.00,9310.20,5967.08,26378.90,,15206.66,,,percent of total billed charges,,Paid in addition to outpatient services ,8142.90,,,fee schedule,,,13034.28,,,percent of total billed charges,,Paid in addition to outpatient services ,15653.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,17129.89,,,fee schedule,,,5967.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8305.76,,,fee schedule,,,18702.20,,,fee schedule,,,,,,,,,8142.90,,,fee schedule,,,,,,,,,13189.45,,,percent of total billed charges,,Paid in addition to outpatient services ,16881.63,,,fee schedule,,,23275.5,,,percent of total billed charges,,,8142.90,,,fee schedule,,,5967.08,,,fee schedule,,,8305.76,,,fee schedule,,,15517.0,,,percent of total billed charges,,Paid in addition to outpatient services ,8142.90,,,fee schedule,,,23275.5,,,percent of total billed charges,,,5967.08,,,fee schedule,,,8305.76,,,fee schedule,,,,,,,,,26378.90,,,percent of total billed charges,,,14275.64,,,percent of total billed charges,,,,,,,,,,,,,,,8142.90,,,fee schedule,,,,,,,,,,,,,,,8142.90,,,fee schedule,,,,,,,,,8224.33,,,fee schedule,,,,,,,,
SCREW COMP HDLS 4X42MM X_658042 X_STRYKER ORTHOPAE,10158183,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP HDLS 4X42MM X_658042 X_STRYKER ORTHOPAE,10158183,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT 16X38X28 8DEG X_6921688 X_NUVASIVE,10158184,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT 16X38X28 8DEG X_6921688 X_NUVASIVE,10158184,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 14MM PERFORM P,10158186,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,677.00,203.10,262.68,575.45,,,,,,,,,,,,,,,,,,,,262.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.45,,,percent of total billed charges,,,304.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 14MM PERFORM P,10158186,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,677.00,203.10,287.72,575.45,,,,,,,,,,,,,service not payable,,,,,,,341.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,507.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,575.45,,,percent of total billed charges,,,311.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 18MM PERFORM P,10158187,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,677.00,203.10,262.68,575.45,,,,,,,,,,,,,,,,,,,,262.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.45,,,percent of total billed charges,,,304.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 18MM PERFORM P,10158187,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,677.00,203.10,287.72,575.45,,,,,,,,,,,,,service not payable,,,,,,,341.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,287.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,507.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,338.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,507.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,575.45,,,percent of total billed charges,,,311.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
POST SHOULDER GLENOID 6.5X30MM,10158188,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POST SHOULDER GLENOID 6.5X30MM,10158188,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE LAT  6MM/25MM X_DWJ503 X_TORNIER INC,10158189,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11145.00,3343.50,4324.26,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9473.25,,,percent of total billed charges,,,5015.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE LAT  6MM/25MM X_DWJ503 X_TORNIER INC,10158189,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11145.00,3343.50,4680.90,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5621.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9473.25,,,percent of total billed charges,,,5126.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING HUM COMP E1  36-44MM,10158190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING HUM COMP E1  36-44MM,10158190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE LUM POST 6D 8X23X9MM,10160723,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE LUM POST 6D 8X23X9MM,10160723,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LEGION FEM LFT NRW SZ5N,10160724,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LEGION FEM LFT NRW SZ5N,10160724,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SZ4 RT 66X.5X60.3 X_NX030Z X_B BRAUN MEDI,10160725,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SZ4 RT 66X.5X60.3 X_NX030Z X_B BRAUN MEDI,10160725,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB CEM AS VEGA 12X52MM,10160726,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB CEM AS VEGA 12X52MM,10160726,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLYAXIAL 6.5X35MM,10160727,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLYAXIAL 6.5X35MM,10160727,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT SEMITENDINOSUS 18CM,10160729,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7901.00,2370.30,3065.59,6715.85,,3871.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3318.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3065.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3357.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6715.85,,,percent of total billed charges,,,3555.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT SEMITENDINOSUS 18CM,10160729,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7901.00,2370.30,3318.42,6715.85,,3871.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3318.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3985.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3357.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6715.85,,,percent of total billed charges,,,3634.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD THREADED 300MM X_102312 X_SMITH NEPHEW,10160730,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD THREADED 300MM X_102312 X_SMITH NEPHEW,10160730,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ RESTOR  2.5D 20.0D X_SV25T5-20.0 X_ALCON L,10160731,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ RESTOR  2.5D 20.0D X_SV25T5-20.0 X_ALCON L,10160731,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CANC 1 TO 4MM 5CC X_27715005 X_STRYKER O,10160732,CDM,0278,RC,C9362,HCPCS,,,,,,inpatient,facility,,,1541.00,462.30,597.91,1309.85,,,,,,,,,,,,,,,,,,,,597.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,654.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.85,,,percent of total billed charges,,,693.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT CANC 1 TO 4MM 5CC X_27715005 X_STRYKER O,10160732,CDM,0278,RC,C9362,HCPCS,,,,,,outpatient,facility,,,1541.00,462.30,654.92,1309.85,,,,,,,,,,,,,service not payable,,,,,,,777.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,654.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1309.85,,,percent of total billed charges,,,708.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CANC 1 TO 4MM 5CC X_27715005 X_STRYKER O,10160732,CDM,0278,RC,C9362,HCPCS,455,EAPG,,,,outpatient,facility,,,1541.00,462.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCESSOR SOUND BAHA 5 BROWN,10160733,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,12302.00,3690.60,4773.18,10456.70,,6027.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5166.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4773.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5228.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9226.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6151.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10456.70,,,percent of total billed charges,,,5535.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCESSOR SOUND BAHA 5 BROWN,10160733,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,12302.00,3690.60,5166.84,10456.70,,6027.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5166.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6205.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5228.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9226.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6151.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9226.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10456.70,,,percent of total billed charges,,,5658.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIX PL 13X6MM 15DIO X_PCB00-15.0 X_PRECISI,10160734,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIX PL 13X6MM 15DIO X_PCB00-15.0 X_PRECISI,10160734,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIXATION EXTERNAL JOINT DIGIT,10160735,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5164.00,1549.20,2003.63,4389.40,,2530.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2168.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2003.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2194.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2582.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4389.40,,,percent of total billed charges,,,2323.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIXATION EXTERNAL JOINT DIGIT,10160735,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5164.00,1549.20,2168.88,4389.40,,2530.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2168.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2604.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2194.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2582.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3873.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4389.40,,,percent of total billed charges,,,2375.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PRELOADED 22.0D,10160736,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PRELOADED 22.0D,10160736,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS FOLDABLE 21.5D X_ZLB00-21.5 X_PRECISIO,10160737,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS FOLDABLE 21.5D X_ZLB00-21.5 X_PRECISIO,10160737,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1956.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1956.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,service not payable,1760.40,,,fee schedule,,,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PRELOADED 14.5D X_PCB00-14.5 X_PRECISI,10160738,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PRELOADED 14.5D X_PCB00-14.5 X_PRECISI,10160738,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF 4X90MM 20 THR X_5023-2-090 X_STRYKER ORTH,10162096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,518.00,155.40,200.98,440.30,,,,,,,,,,,,,,,,,,,,200.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,388.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,259.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,440.30,,,percent of total billed charges,,,233.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF 4X90MM 20 THR X_5023-2-090 X_STRYKER ORTH,10162096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,518.00,155.40,220.15,440.30,,,,,,,,,,,,,service not payable,,,,,,,261.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,220.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,388.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,259.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,388.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,440.30,,,percent of total billed charges,,,238.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BATTERY GENERATOR NEUROSTIM,10162099,CDM,0274,RC,L8679,HCPCS,,,,,,inpatient,facility,,,35623.00,10686.90,13821.72,30279.55,,17455.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14961.66,,,percent of total billed charges,,Paid in addition to inpatient services ,13821.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15139.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,26717.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17811.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30279.55,,,percent of total billed charges,,,16030.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BATTERY GENERATOR NEUROSTIM,10162099,CDM,0274,RC,L8679,HCPCS,,,,,,outpatient,facility,,,35623.00,10686.90,14961.66,30279.55,,17455.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14961.66,,,percent of total billed charges,,Paid in addition to outpatient services ,17968.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15139.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,26717.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,17811.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,26717.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,30279.55,,,percent of total billed charges,,,16386.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROGRAMMER PT NEUROSTIMULATOR,10162100,CDM,0274,RC,C1787,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,,percent of total billed charges,,Paid in addition to inpatient services ,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROGRAMMER PT NEUROSTIMULATOR,10162100,CDM,0274,RC,C1787,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,,percent of total billed charges,,Paid in addition to outpatient services ,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 4.5X18MM X_AR-8545-18 X_ARTHREX INC,10162101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 4.5X18MM X_AR-8545-18 X_ARTHREX INC,10162101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5.5X40MM X_AR-8555-40 X_ARTHREX INC,10162102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5.5X40MM X_AR-8555-40 X_ARTHREX INC,10162102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DISTAL FIBULA LT 4H X_AR-8963APLL-04 X_ARTHR,10162103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DISTAL FIBULA LT 4H X_AR-8963APLL-04 X_ARTHR,10162103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NL LP 24X2.7MM,10162104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NL LP 24X2.7MM,10162104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 SIZE 2,10162105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 SIZE 2,10162105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SNC PL 4X60MM X_7382-5260 X_SMITH NEPHEW,10162106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,148.00,44.40,57.42,125.8,,,,,,,,,,,,,,,,,,,,57.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,66.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SNC PL 4X60MM X_7382-5260 X_SMITH NEPHEW,10162106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,,,,,,,,,,,,service not payable,,,,,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT PROX X_VAMF4242C100TU X_MEDTRONIC USA,10162107,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,37142.00,11142.60,14411.10,31570.70,,18199.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15599.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14411.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15785.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27856.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18571.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31570.70,,,percent of total billed charges,,,16713.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT PROX X_VAMF4242C100TU X_MEDTRONIC USA,10162107,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,37142.00,11142.60,15599.64,31570.70,,18199.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15599.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18734.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15785.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27856.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18571.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27856.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31570.70,,,percent of total billed charges,,,17085.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL HEAD W/NECK FF 4.8XM X_AT447FF X_PRECISION,10162108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL HEAD W/NECK FF 4.8XM X_AT447FF X_PRECISION,10162108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 5 DIO,10162114,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 5 DIO,10162114,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 5.5 DIO,10162115,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 5.5 DIO,10162115,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 6 DIO,10162116,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 6 DIO,10162116,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 6.5 DIO,10162117,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 6.5 DIO,10162117,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 7 DIO,10162118,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 7 DIO,10162118,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 7.5 DIO,10162119,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 7.5 DIO,10162119,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 8 DIO X_PCB00-8.0 X_PRECISIO,10162120,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 8 DIO X_PCB00-8.0 X_PRECISIO,10162120,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 8.5 DIO,10162121,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 8.5 DIO,10162121,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 9 DIO,10162122,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 9 DIO,10162122,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 9.5 DIO X_PCB00-9.5 X_PRECIS,10162123,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 9.5 DIO X_PCB00-9.5 X_PRECIS,10162123,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 10 DIO X_PCB00-10.0 X_PRECIS,10162124,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 10 DIO X_PCB00-10.0 X_PRECIS,10162124,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 10.5 DIO X_PCB00-10.5 X_PREC,10162125,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 10.5 DIO X_PCB00-10.5 X_PREC,10162125,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 11 DIO X__PCB00-11.0 X_PRECI,10162126,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 11 DIO X__PCB00-11.0 X_PRECI,10162126,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 11.5 DIO X_PCB00-11.5 X_PREC,10162127,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 11.5 DIO X_PCB00-11.5 X_PREC,10162127,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 12 DIO X_PCB00-12.0 X_PRECIS,10162128,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 12 DIO X_PCB00-12.0 X_PRECIS,10162128,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 12.5 DIO X_PCB00-12.5 X_PREC,10162129,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 12.5 DIO X_PCB00-12.5 X_PREC,10162129,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 13 DIO,10162130,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 13 DIO,10162130,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 13.5 DIO X_PCB00-13.5 X_PREC,10162131,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 13.5 DIO X_PCB00-13.5 X_PREC,10162131,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 15.5 DIO X_PCB00-15.5 X_PREC,10162132,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 15.5 DIO X_PCB00-15.5 X_PREC,10162132,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 16 DIO X_PCB00-16.0 X_PRECIS,10162133,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 16 DIO X_PCB00-16.0 X_PRECIS,10162133,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 17 DIO,10162134,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 17 DIO,10162134,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 17.5 DIO,10162135,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 17.5 DIO,10162135,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 18.5 DIO,10162136,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 18.5 DIO,10162136,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 19 DIO,10162137,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 19 DIO,10162137,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 19.5 DIO X_PCB00-19.5 X_PREC,10162138,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 19.5 DIO X_PCB00-19.5 X_PREC,10162138,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 20 DIO X_PCB00-20.0 X_PRECIS,10162139,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 20 DIO X_PCB00-20.0 X_PRECIS,10162139,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 21 DIO X_PCB00-21.0 X_PRECIS,10162140,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 21 DIO X_PCB00-21.0 X_PRECIS,10162140,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 21.5 DIO,10162141,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 21.5 DIO,10162141,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 22.5 DIO X_PCB00-22.5 X_PREC,10162142,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 22.5 DIO X_PCB00-22.5 X_PREC,10162142,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 23 DIO,10162143,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 23 DIO,10162143,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 23.5 DIO X_PCB00-23.5 X_PREC,10162144,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 23.5 DIO X_PCB00-23.5 X_PREC,10162144,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 24 DIO X_PCB00-24.0 X_PRECIS,10162145,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 24 DIO X_PCB00-24.0 X_PRECIS,10162145,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 24.5 DIO,10162146,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 24.5 DIO,10162146,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 25.5 DIO,10162147,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 25.5 DIO,10162147,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 26 DIO X_PCB00-26.0 X_PRECIS,10162148,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 26 DIO X_PCB00-26.0 X_PRECIS,10162148,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 26.5 DIO X_PCB00-26.5 X_PREC,10162149,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 26.5 DIO X_PCB00-26.5 X_PREC,10162149,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 27 DIO X_PCB00-27.0 X_PRECIS,10162150,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 27 DIO X_PCB00-27.0 X_PRECIS,10162150,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 27.5 DIO X_PCB00-27.5 X_PREC,10162151,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 27.5 DIO X_PCB00-27.5 X_PREC,10162151,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 28 DIO X_PCB00-28.0 X_PRECIS,10162152,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 28 DIO X_PCB00-28.0 X_PRECIS,10162152,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 28.5 DIO X_PCB00-28.5 X_PREC,10162153,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 28.5 DIO X_PCB00-28.5 X_PREC,10162153,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 29 DIO X_PCB00-29.0 X_PRECIS,10162154,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 29 DIO X_PCB00-29.0 X_PRECIS,10162154,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 29.5 DIO X_PCB00-29.5 X_PREC,10162155,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 29.5 DIO X_PCB00-29.5 X_PREC,10162155,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 30 DIO,10162156,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 30 DIO,10162156,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 30.5 DIO X_PCB00-30.5 X_PREC,10162157,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 30.5 DIO X_PCB00-30.5 X_PREC,10162157,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 31 DIO,10162158,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 31 DIO,10162158,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 31.5 DIO X_PCB00-31.5 X_PREC,10162159,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 31.5 DIO X_PCB00-31.5 X_PREC,10162159,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 32 DIO X_PCB00-32.0 X_PRECIS,10162160,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 32 DIO X_PCB00-32.0 X_PRECIS,10162160,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 32.5 DIO X_PCB00-32.5 X_PREC,10162161,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 32.5 DIO X_PCB00-32.5 X_PREC,10162161,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 33 DIO,10162162,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 33 DIO,10162162,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 33.5 DIO,10162163,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 33.5 DIO,10162163,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS PL 13X6MM 34 DIO,10162164,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS PL 13X6MM 34 DIO,10162164,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ8 10MM,10162166,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ8 10MM,10162166,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10162618,CDM,0360,RC,33340,CPT,,,,,,outpatient,facility,,,46770.00,14031.00,721.38,39754.5,,13476.59,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,10719.0,,,case rate,,,23590.79,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,721.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,35077.5,,,percent of total billed charges,,,,,,,,service not payable,721.38,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,35077.5,,,percent of total billed charges,,,721.38,,,fee schedule,,,,,,,,service not payable,,,,,,,39754.5,,,percent of total billed charges,,,21514.20,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10162618,CDM,0360,RC,33340,CPT,121,EAPG,,,,outpatient,facility,,,46770.00,14031.00,16810.68,37849.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37849.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,32171.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16810.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,18491.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR SUTURE Q FIX 1.8MM,10164351,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE Q FIX 1.8MM,10164351,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP PT TI 6.0X40MM,10164353,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP PT TI 6.0X40MM,10164353,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI LK LP 3.0X28MM,10164355,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI LK LP 3.0X28MM,10164355,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSION CERVICAL 14X16X6 X_1000-00-0616 X_NU,10164356,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSION CERVICAL 14X16X6 X_1000-00-0616 X_NU,10164356,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PLATINUM WT 1.6GM,10164357,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2382.00,714.60,924.22,2024.7,,,,,,,,,,,,,,,,,,,,924.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1012.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1786.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1191.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2024.7,,,percent of total billed charges,,,1071.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PLATINUM WT 1.6GM,10164357,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2382.00,714.60,1012.35,2024.7,,,,,,,,,,,,,service not payable,,,,,,,1201.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1012.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1786.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1191.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1786.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2024.7,,,percent of total billed charges,,,1095.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 7F 130X40,10164358,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SEMITENDENOSIS CUSTOM X_TISSUE X_STRYKER ENDOSCOPY,10164359,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7901.00,2370.30,3065.59,6715.85,,3871.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3318.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3065.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3357.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6715.85,,,percent of total billed charges,,,3555.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SEMITENDENOSIS CUSTOM X_TISSUE X_STRYKER ENDOSCOPY,10164359,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7901.00,2370.30,3318.42,6715.85,,3871.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3318.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3985.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3357.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6715.85,,,percent of total billed charges,,,3634.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 10.5 X_SN6AT4-10.5 X_ALCON LAB,10164361,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 10.5 X_SN6AT4-10.5 X_ALCON LAB,10164361,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BIO-TENODESIS 5.5X15MM,10164366,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIO-TENODESIS 5.5X15MM,10164366,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TENSION BAND 0.062INX90MM,10164369,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,257.00,77.10,99.72,218.45,,,,,,,,,,,,,,,,,,,,99.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,192.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.45,,,percent of total billed charges,,,115.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TENSION BAND 0.062INX90MM,10164369,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,257.00,77.10,109.22,218.45,,,,,,,,,,,,,service not payable,,,,,,,129.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,109.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,192.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,128.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,192.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,218.45,,,percent of total billed charges,,,118.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PRECRYO CRYOPROBE 2.4MM,10164372,CDM,0272,RC,C2618,HCPCS,,,,,,outpatient,facility,,,3930.00,1179.00,1670.25,3340.5,,2428.74,,,percent of total billed charges,,,,,,,,service not payable,1917.84,,,percent of total billed charges,,,1982.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1670.25,,,percent of total billed charges,,,,,,,,,2947.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1965.0,,,percent of total billed charges,,,,,,,,service not payable,2947.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3340.5,,,percent of total billed charges,,,1807.8,,,percent of total billed charges,,,,,,,,,2554.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2554.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACK CONSTELLATN 10K CPM 25G,10164375,CDM,0272,RC,A4550,HCPCS,,,,,,outpatient,facility,,,2575.00,772.50,1094.38,2188.75,,1591.35,,,percent of total billed charges,,,,,,,,service not payable,1256.60,,,percent of total billed charges,,,1298.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1094.38,,,percent of total billed charges,,,,,,,,,1931.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1287.5,,,percent of total billed charges,,,,,,,,service not payable,1931.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2188.75,,,percent of total billed charges,,,1184.5,,,percent of total billed charges,,,,,,,,,1673.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1673.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 2.5X30MM X_IH2530 X_STRYKER ORTHOPAEDIC,10168099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2241.00,672.30,869.51,1904.85,,,,,,,,,,,,,,,,,,,,869.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1680.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1120.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1904.85,,,percent of total billed charges,,,1008.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 2.5X30MM X_IH2530 X_STRYKER ORTHOPAEDIC,10168099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2241.00,672.30,952.42,1904.85,,,,,,,,,,,,,service not payable,,,,,,,1130.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,952.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1680.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1120.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1680.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1904.85,,,percent of total billed charges,,,1030.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 2.5X40MM,10168100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2241.00,672.30,869.51,1904.85,,,,,,,,,,,,,,,,,,,,869.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1680.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1120.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1904.85,,,percent of total billed charges,,,1008.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X40MM,10168100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2241.00,672.30,952.42,1904.85,,,,,,,,,,,,,service not payable,,,,,,,1130.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,952.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1680.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1120.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1680.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1904.85,,,percent of total billed charges,,,1030.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT INFINION CX 50CM,10168101,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT INFINION CX 50CM,10168101,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER FLEX FLO X_G07878 X_COOK MEDICAL INC,10168102,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINE ACETABULAR 36X62MM X_71338562 X_SMITH NEPHEW,10168103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2143.00,642.90,831.48,1821.55,,,,,,,,,,,,,,,,,,,,831.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1607.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1071.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1821.55,,,percent of total billed charges,,,964.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINE ACETABULAR 36X62MM X_71338562 X_SMITH NEPHEW,10168103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2143.00,642.90,910.77,1821.55,,,,,,,,,,,,,service not payable,,,,,,,1080.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,910.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1607.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1071.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1607.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1821.55,,,percent of total billed charges,,,985.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 1.5X5MM X_56-15905 X_STRYKER,10168104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,541.00,162.30,209.91,459.85,,,,,,,,,,,,,,,,,,,,209.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,405.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,459.85,,,percent of total billed charges,,,243.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 1.5X5MM X_56-15905 X_STRYKER,10168104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,541.00,162.30,229.92,459.85,,,,,,,,,,,,,service not payable,,,,,,,272.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,229.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,405.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,405.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,459.85,,,percent of total billed charges,,,248.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MEDIAL 9H LCKG X_PL-LEM9S X_ACUMED,10168105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4144.00,1243.20,1607.87,3522.40,,,,,,,,,,,,,,,,,,,,1607.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1761.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3108.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2072.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3522.40,,,percent of total billed charges,,,1864.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MEDIAL 9H LCKG X_PL-LEM9S X_ACUMED,10168105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4144.00,1243.20,1761.2,3522.40,,,,,,,,,,,,,service not payable,,,,,,,2090.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1761.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3108.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2072.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3108.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3522.40,,,percent of total billed charges,,,1906.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RESCUE 4.35X16MM X_48814516 X_STRYKER,10168106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RESCUE 4.35X16MM X_48814516 X_STRYKER,10168106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BAHA5 POWER SILVER,10168108,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,12302.00,3690.60,4773.18,10456.70,,6027.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5166.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4773.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5228.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9226.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6151.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10456.70,,,percent of total billed charges,,,5535.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BAHA5 POWER SILVER,10168108,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,12302.00,3690.60,5166.84,10456.70,,6027.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5166.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6205.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5228.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9226.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6151.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9226.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10456.70,,,percent of total billed charges,,,5658.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
POWER BAHA5 BLACK X_95471 X_COCHLEAR AMERICAS,10168109,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,12302.00,3690.60,4773.18,10456.70,,6027.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5166.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4773.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5228.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9226.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6151.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10456.70,,,percent of total billed charges,,,5535.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POWER BAHA5 BLACK X_95471 X_COCHLEAR AMERICAS,10168109,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,12302.00,3690.60,5166.84,10456.70,,6027.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5166.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6205.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5228.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9226.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6151.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9226.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10456.70,,,percent of total billed charges,,,5658.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH OUTBACK ELITE 6F 120CM X_OTB59120A X_ALLEGIAN,10168111,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,7534.00,2260.20,3201.95,6403.90,,4656.01,,,percent of total billed charges,,,,,,,,service not payable,3676.59,,,percent of total billed charges,,,3800.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3201.95,,,percent of total billed charges,,,,,,,,,5650.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.0,,,percent of total billed charges,,,,,,,,service not payable,5650.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6403.90,,,percent of total billed charges,,,3465.64,,,percent of total billed charges,,,,,,,,,4897.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4897.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo BRAF Mutation (81210),10168273,CDM,0310,RC,81210,CPT,,,,,,outpatient,facility,,,221.00,66.30,101.66,396.40,,221.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,171.89,,,fee schedule,,,221.0,,,fee schedule,,,365.80,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,363.08,,,fee schedule,,,166.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",175.33,,,fee schedule,,,396.40,,,fee schedule,,,,,,,,,171.89,,,fee schedule,,,,,,,,,225.80,,,fee schedule,,,357.82,,,fee schedule,,,165.75,,,percent of total billed charges,,,171.89,,,fee schedule,,,166.63,,,fee schedule,,,175.33,,,fee schedule,,,265.55,,,fee schedule,,,171.89,,,fee schedule,,,165.75,,,percent of total billed charges,,,166.63,,,fee schedule,,,175.33,,,fee schedule,,,,,,,,,187.85,,,percent of total billed charges,,,101.66,,,percent of total billed charges,,,,,,,,,192.94,,,fee schedule,,,171.89,,,fee schedule,,,,,,,,,170.14,,,fee schedule,,,171.89,,,fee schedule,,,,,,,,,173.61,,,fee schedule,,,,,,,,
Neo BRAF Mutation (81210),10168273,CDM,0310,RC,81210,CPT,386,EAPG,,,,outpatient,facility,,,221.00,66.30,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo Consult/Report (88323 Global),10168274,CDM,0310,RC,88323,CPT,,,,,,outpatient,facility,,,298.00,89.40,37.21,253.30,,178.71,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,133.35,,,fee schedule,,,228.43,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.21,,,fee schedule,,,,,,,,,223.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.76,,,fee schedule,,,,,,,,,223.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,253.30,,,percent of total billed charges,,,137.08,,,percent of total billed charges,,,,,,,,,56.79,,,fee schedule,,,,,,,,,,,,,,,50.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo Consult/Report (88323 Global),10168274,CDM,0310,RC,88323,CPT,05671,APC,,,,outpatient,facility,,,298.00,89.40,49.15,117.68,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,107.78,,,fee schedule,,,49.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",52.26,,,fee schedule,,,117.68,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,106.22,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,49.15,,,fee schedule,,,52.26,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,,,,,,,49.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",52.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,51.24,,,fee schedule,,,,,,,,,51.75,,,fee schedule,,,,,,,,
Neo Consult/Report (88323 Global),10168274,CDM,0310,RC,88323,CPT,158,EAPG,,,,outpatient,facility,,,298.00,89.40,61.38,136.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,121.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,121.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,61.38,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,67.52,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo DNA Flow (88182 Global),10168275,CDM,0310,RC,88182,CPT,,,,,,outpatient,facility,,,165.00,49.50,50.08,310.88,,165.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,152.96,,,fee schedule,,,310.88,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.89,,,fee schedule,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,191.56,,,fee schedule,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,56.79,,,fee schedule,,,,,,,,,,,,,,,50.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo DNA Flow (88182 Global),10168275,CDM,0310,RC,88182,CPT,05671,APC,,,,outpatient,facility,,,165.00,49.50,49.15,117.68,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,107.78,,,fee schedule,,,49.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",52.26,,,fee schedule,,,117.68,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,106.22,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,49.15,,,fee schedule,,,52.26,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,,,,,,,49.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",52.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,51.24,,,fee schedule,,,,,,,,,51.75,,,fee schedule,,,,,,,,
Neo DNA Flow (88182 Global),10168275,CDM,0310,RC,88182,CPT,391,EAPG,,,,outpatient,facility,,,165.00,49.50,38.68,377.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,320.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.68,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.68,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.68,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,59.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,65.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo EGFR Mutation (81235),10168276,CDM,0310,RC,81235,CPT,,,,,,outpatient,facility,,,421.00,126.30,193.66,733.55,,421.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,318.09,,,fee schedule,,,421.0,,,fee schedule,,,676.91,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,671.88,,,fee schedule,,,308.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",324.45,,,fee schedule,,,733.55,,,fee schedule,,,,,,,,,318.09,,,fee schedule,,,,,,,,,417.48,,,fee schedule,,,662.14,,,fee schedule,,,315.75,,,percent of total billed charges,,,318.09,,,fee schedule,,,308.35,,,fee schedule,,,324.45,,,fee schedule,,,490.97,,,fee schedule,,,318.09,,,fee schedule,,,315.75,,,percent of total billed charges,,,308.35,,,fee schedule,,,324.45,,,fee schedule,,,,,,,,,357.85,,,percent of total billed charges,,,193.66,,,percent of total billed charges,,,,,,,,,357.04,,,fee schedule,,,318.09,,,fee schedule,,,,,,,,,314.84,,,fee schedule,,,318.09,,,fee schedule,,,,,,,,,321.27,,,fee schedule,,,,,,,,
Neo EGFR Mutation (81235),10168276,CDM,0310,RC,81235,CPT,387,EAPG,,,,outpatient,facility,,,421.00,126.30,275.90,649.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,552.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,421.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,421.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,275.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,303.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FISH Auto (88374 Global),10168277,CDM,0310,RC,88374,CPT,,,,,,outpatient,facility,,,482.00,144.60,157.86,588.09,,453.78,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,338.60,,,fee schedule,,,588.09,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.89,,,fee schedule,,,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,366.80,,,fee schedule,,,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,409.70,,,percent of total billed charges,,,221.72,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo FISH Auto (88374 Global),10168277,CDM,0310,RC,88374,CPT,05672,APC,,,,outpatient,facility,,,482.00,144.60,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo FISH Auto (88374 Global),10168277,CDM,0310,RC,88374,CPT,306,EAPG,,,,outpatient,facility,,,482.00,144.60,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FISH Manual (88377 Global),10168278,CDM,0310,RC,88377,CPT,,,,,,outpatient,facility,,,482.00,144.60,157.86,769.26,,422.21,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,315.04,,,fee schedule,,,769.26,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.84,,,fee schedule,,,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,494.93,,,fee schedule,,,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,409.70,,,percent of total billed charges,,,221.72,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo FISH Manual (88377 Global),10168278,CDM,0310,RC,88377,CPT,05672,APC,,,,outpatient,facility,,,482.00,144.60,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo FISH Manual (88377 Global),10168278,CDM,0310,RC,88377,CPT,306,EAPG,,,,outpatient,facility,,,482.00,144.60,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FLT3 Mutation (81245 81246),10168279,CDM,0310,RC,81479,CPT,,,,,,outpatient,facility,,,360.00,108.00,153.0,306.0,,222.48,,,percent of total billed charges,,,,,,,,service not payable,177.12,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.0,,,percent of total billed charges,,,,,,,,,270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,180.0,,,percent of total billed charges,,,,,,,,service not payable,270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,,165.60,,,percent of total billed charges,,,,,,,,,180.0,,,fee schedule,,,,,,,,service not payable,,,,,,,180.0,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo FLT3 Mutation (81245 81246),10168279,CDM,0310,RC,81479,CPT,385,EAPG,,,,outpatient,facility,,,360.00,108.00,54.96,331.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,281.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,94.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,104.35,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Addl by ISH (88364 Global),10168280,CDM,0310,RC,88364,CPT,,,,,,outpatient,facility,,,176.00,52.80,80.96,266.00,,176.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,148.54,,,fee schedule,,,266.00,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,126.94,,,fee schedule,,,,,,,,,132.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,149.29,,,fee schedule,,,,,,,,service not payable,132.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,149.60,,,percent of total billed charges,,,80.96,,,percent of total billed charges,,,,,,,,,108.78,,,fee schedule,,,,,,,,service not payable,,,,,,,95.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo IHC Addl by ISH (88364 Global),10168280,CDM,0310,RC,88364,CPT,305,EAPG,,,,outpatient,facility,,,176.00,52.80,46.86,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.08,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,91.39,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Addl by ISH (88364 TC),10168281,CDM,0310,RC,88364,CPT,,,,,TC  ,outpatient,facility,,,120.00,36.00,55.20,198.27,,120.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,120.0,,,fee schedule,,,198.27,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,126.94,,,fee schedule,,,,,,,,,90.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,149.29,,,fee schedule,,,,,,,,service not payable,90.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,102.0,,,percent of total billed charges,,,55.20,,,percent of total billed charges,,,,,,,,,108.78,,,fee schedule,,,,,,,,service not payable,,,,,,,95.92,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo IHC Addl by ISH (88364 TC),10168281,CDM,0310,RC,88364,CPT,305,EAPG,,,TC  ,outpatient,facility,,,120.00,36.00,46.86,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.08,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,91.39,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC by ISH (88365 Global),10168282,CDM,0310,RC,88365,CPT,,,,,,outpatient,facility,,,232.00,69.60,106.72,351.18,,232.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,232.0,,,fee schedule,,,351.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.32,,,fee schedule,,,,,,,,,174.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.48,,,fee schedule,,,,,,,,,174.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.20,,,percent of total billed charges,,,106.72,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC by ISH (88365 Global),10168282,CDM,0310,RC,88365,CPT,05672,APC,,,,outpatient,facility,,,232.00,69.60,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo IHC by ISH (88365 Global),10168282,CDM,0310,RC,88365,CPT,306,EAPG,,,,outpatient,facility,,,232.00,69.60,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC by ISH (88365 TC),10168283,CDM,0310,RC,88365,CPT,,,,,TC  ,outpatient,facility,,,177.00,53.10,81.42,265.57,,177.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,177.0,,,fee schedule,,,265.57,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.32,,,fee schedule,,,,,,,,,132.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.48,,,fee schedule,,,,,,,,,132.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.45,,,percent of total billed charges,,,81.42,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC by ISH (88365 TC),10168283,CDM,0310,RC,88365,CPT,05672,APC,,,TC  ,outpatient,facility,,,177.00,53.10,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo IHC by ISH (88365 TC),10168283,CDM,0310,RC,88365,CPT,306,EAPG,,,TC  ,outpatient,facility,,,177.00,53.10,177.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,177.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,177.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Morph Comp Assist (88361 Global),10168284,CDM,0312,RC,88361,CPT,,,,,,outpatient,facility,,,211.00,63.30,97.06,376.73,,211.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,211.0,,,fee schedule,,,232.05,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,158.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,158.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,,97.06,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC Morph Comp Assist (88361 Global),10168284,CDM,0312,RC,88361,CPT,05673,APC,,,,outpatient,facility,,,211.00,63.30,211.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,211.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,211.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo IHC Morph Comp Assist (88361 Global),10168284,CDM,0312,RC,88361,CPT,306,EAPG,,,,outpatient,facility,,,211.00,63.30,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Morph Comp Assist (88361 TC),10168285,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,149.00,44.70,68.54,376.73,,149.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,149.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC Morph Comp Assist (88361 TC),10168285,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,149.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,149.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo IHC Morph Comp Assist (88361 TC),10168285,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Qual (88342 Global),10168286,CDM,0310,RC,88342,CPT,,,,,,outpatient,facility,,,165.00,49.50,75.90,195.68,,153.23,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,114.33,,,fee schedule,,,195.68,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.14,,,fee schedule,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.18,,,fee schedule,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC Qual (88342 Global),10168286,CDM,0310,RC,88342,CPT,05672,APC,,,,outpatient,facility,,,165.00,49.50,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo IHC Qual (88342 Global),10168286,CDM,0310,RC,88342,CPT,306,EAPG,,,,outpatient,facility,,,165.00,49.50,165.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Qual (88342 TC),10168287,CDM,0310,RC,88342,CPT,,,,,TC  ,outpatient,facility,,,126.00,37.80,57.96,179.01,,126.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,114.33,,,fee schedule,,,126.65,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.14,,,fee schedule,,,,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.18,,,fee schedule,,,,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.10,,,percent of total billed charges,,,57.96,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC Qual (88342 TC),10168287,CDM,0310,RC,88342,CPT,05672,APC,,,TC  ,outpatient,facility,,,126.00,37.80,126.0,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,126.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,126.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo IHC Qual (88342 TC),10168287,CDM,0310,RC,88342,CPT,306,EAPG,,,TC  ,outpatient,facility,,,126.00,37.80,126.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,126.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,126.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Qual Addl (88341 Global),10168288,CDM,0310,RC,88341,CPT,,,,,,outpatient,facility,,,110.00,33.00,50.60,168.82,,110.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,96.86,,,fee schedule,,,168.82,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.46,,,fee schedule,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.63,,,fee schedule,,,,,,,,service not payable,82.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,93.5,,,percent of total billed charges,,,50.60,,,percent of total billed charges,,,,,,,,,68.79,,,fee schedule,,,,,,,,service not payable,,,,,,,60.66,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo IHC Qual Addl (88341 Global),10168288,CDM,0310,RC,88341,CPT,305,EAPG,,,,outpatient,facility,,,110.00,33.00,46.86,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.08,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,91.39,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Qual Addl (88341 TC),10168289,CDM,0310,RC,88341,CPT,,,,,TC  ,outpatient,facility,,,71.00,21.30,32.66,112.91,,71.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,71.0,,,fee schedule,,,112.91,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.46,,,fee schedule,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.63,,,fee schedule,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,68.79,,,fee schedule,,,,,,,,service not payable,,,,,,,60.66,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo IHC Qual Addl (88341 TC),10168289,CDM,0310,RC,88341,CPT,305,EAPG,,,TC  ,outpatient,facility,,,71.00,21.30,46.86,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.08,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,91.39,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Quant (88360 Global),10168290,CDM,0310,RC,88360,CPT,,,,,,outpatient,facility,,,185.00,55.50,85.10,231.43,,185.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,170.60,,,fee schedule,,,231.43,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,fee schedule,,,,,,,,,138.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.06,,,fee schedule,,,,,,,,,138.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,157.25,,,percent of total billed charges,,,85.10,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC Quant (88360 Global),10168290,CDM,0310,RC,88360,CPT,05672,APC,,,,outpatient,facility,,,185.00,55.50,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo IHC Quant (88360 Global),10168290,CDM,0310,RC,88360,CPT,306,EAPG,,,,outpatient,facility,,,185.00,55.50,185.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,185.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,185.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo IHC Quant (88360 TC),10168291,CDM,0312,RC,88360,CPT,,,,,TC  ,outpatient,facility,,,135.00,40.50,62.10,179.01,,135.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,135.0,,,fee schedule,,,148.59,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,fee schedule,,,,,,,,,101.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.06,,,fee schedule,,,,,,,,,101.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.75,,,percent of total billed charges,,,62.10,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo IHC Quant (88360 TC),10168291,CDM,0312,RC,88360,CPT,05672,APC,,,TC  ,outpatient,facility,,,135.00,40.50,135.0,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,135.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,135.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo IHC Quant (88360 TC),10168291,CDM,0312,RC,88360,CPT,306,EAPG,,,TC  ,outpatient,facility,,,135.00,40.50,135.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,135.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,135.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo KIT (C-KIT) Mutation (81272),10168292,CDM,0310,RC,81272,CPT,,,,,,outpatient,facility,,,391.00,117.30,179.86,744.69,,241.64,,,percent of total billed charges,,,322.92,,,fee schedule,,,192.37,,,fee schedule,,,687.20,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,682.09,,,fee schedule,,,313.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",329.38,,,fee schedule,,,744.69,,,fee schedule,,,,,,,,,322.92,,,fee schedule,,,,,,,,,423.80,,,fee schedule,,,672.20,,,fee schedule,,,293.25,,,percent of total billed charges,,,322.92,,,fee schedule,,,313.03,,,fee schedule,,,329.38,,,fee schedule,,,498.42,,,fee schedule,,,322.92,,,fee schedule,,,293.25,,,percent of total billed charges,,,313.03,,,fee schedule,,,329.38,,,fee schedule,,,,,,,,,332.35,,,percent of total billed charges,,,179.86,,,percent of total billed charges,,,,,,,,,362.46,,,fee schedule,,,322.92,,,fee schedule,,,,,,,,,319.62,,,fee schedule,,,322.92,,,fee schedule,,,,,,,,,326.15,,,fee schedule,,,,,,,,
Neo KIT (C-KIT) Mutation (81272),10168292,CDM,0310,RC,81272,CPT,386,EAPG,,,,outpatient,facility,,,391.00,117.30,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo KRAS Mutation (81479),10168293,CDM,0310,RC,81479,CPT,,,,,,outpatient,facility,,,524.00,157.20,222.70,445.40,,323.83,,,percent of total billed charges,,,,,,,,service not payable,257.81,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,222.70,,,percent of total billed charges,,,,,,,,,393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,262.0,,,percent of total billed charges,,,,,,,,service not payable,393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,445.40,,,percent of total billed charges,,,241.04,,,percent of total billed charges,,,,,,,,,262.0,,,fee schedule,,,,,,,,service not payable,,,,,,,262.0,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo KRAS Mutation (81479),10168293,CDM,0310,RC,81479,CPT,385,EAPG,,,,outpatient,facility,,,524.00,157.20,54.96,331.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,281.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,94.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,104.35,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo MGMT (81287),10168295,CDM,0310,RC,81287,CPT,,,,,,outpatient,facility,,,408.00,122.40,118.41,346.80,,252.14,,,percent of total billed charges,,,122.15,,,fee schedule,,,200.74,,,fee schedule,,,259.94,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,258.0,,,fee schedule,,,118.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",124.59,,,fee schedule,,,281.69,,,fee schedule,,,,,,,,,122.15,,,fee schedule,,,,,,,,,160.5,,,fee schedule,,,254.27,,,fee schedule,,,306.0,,,percent of total billed charges,,,122.15,,,fee schedule,,,118.41,,,fee schedule,,,124.59,,,fee schedule,,,188.76,,,fee schedule,,,122.15,,,fee schedule,,,306.0,,,percent of total billed charges,,,118.41,,,fee schedule,,,124.59,,,fee schedule,,,,,,,,,346.80,,,percent of total billed charges,,,187.68,,,percent of total billed charges,,,,,,,,,137.10,,,fee schedule,,,122.15,,,fee schedule,,,,,,,,,120.90,,,fee schedule,,,122.15,,,fee schedule,,,,,,,,,123.37,,,fee schedule,,,,,,,,
Neo MGMT (81287),10168295,CDM,0310,RC,81287,CPT,385,EAPG,,,,outpatient,facility,,,408.00,122.40,54.96,331.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,281.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,94.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,104.35,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo MLH1 Promoter Methylation (81288),10168296,CDM,0310,RC,81288,CPT,,,,,,outpatient,facility,,,453.00,135.90,182.70,434.64,,279.95,,,percent of total billed charges,,,188.47,,,fee schedule,,,222.88,,,fee schedule,,,401.09,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,398.10,,,fee schedule,,,182.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",192.24,,,fee schedule,,,434.64,,,fee schedule,,,,,,,,,188.47,,,fee schedule,,,,,,,,,247.29,,,fee schedule,,,392.33,,,fee schedule,,,339.75,,,percent of total billed charges,,,188.47,,,fee schedule,,,182.70,,,fee schedule,,,192.24,,,fee schedule,,,290.83,,,fee schedule,,,188.47,,,fee schedule,,,339.75,,,percent of total billed charges,,,182.70,,,fee schedule,,,192.24,,,fee schedule,,,,,,,,,385.05,,,percent of total billed charges,,,208.38,,,percent of total billed charges,,,,,,,,,211.55,,,fee schedule,,,188.47,,,fee schedule,,,,,,,,,186.55,,,fee schedule,,,188.47,,,fee schedule,,,,,,,,,190.36,,,fee schedule,,,,,,,,
Neo MLH1 Promoter Methylation (81288),10168296,CDM,0310,RC,81288,CPT,386,EAPG,,,,outpatient,facility,,,453.00,135.90,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo MSI (81301),10168297,CDM,0310,RC,81301,CPT,,,,,,outpatient,facility,,,646.00,193.80,297.16,787.75,,646.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,341.59,,,fee schedule,,,646.0,,,fee schedule,,,726.92,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,721.52,,,fee schedule,,,331.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",348.42,,,fee schedule,,,787.75,,,fee schedule,,,,,,,,,341.59,,,fee schedule,,,,,,,,,448.23,,,fee schedule,,,711.06,,,fee schedule,,,484.5,,,percent of total billed charges,,,341.59,,,fee schedule,,,331.13,,,fee schedule,,,348.42,,,fee schedule,,,527.14,,,fee schedule,,,341.59,,,fee schedule,,,484.5,,,percent of total billed charges,,,331.13,,,fee schedule,,,348.42,,,fee schedule,,,,,,,,,549.10,,,percent of total billed charges,,,297.16,,,percent of total billed charges,,,,,,,,,383.42,,,fee schedule,,,341.59,,,fee schedule,,,,,,,,,338.10,,,fee schedule,,,341.59,,,fee schedule,,,,,,,,,345.01,,,fee schedule,,,,,,,,
Neo MSI (81301),10168297,CDM,0310,RC,81301,CPT,386,EAPG,,,,outpatient,facility,,,646.00,193.80,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo PD-L1 (88360 Global),10168299,CDM,0310,RC,88360,CPT,,,,,,outpatient,facility,,,276.00,82.80,101.24,234.60,,228.64,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,170.60,,,fee schedule,,,231.43,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,fee schedule,,,,,,,,,207.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.06,,,fee schedule,,,,,,,,,207.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,234.60,,,percent of total billed charges,,,126.96,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo PD-L1 (88360 Global),10168299,CDM,0310,RC,88360,CPT,05672,APC,,,,outpatient,facility,,,276.00,82.80,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo PD-L1 (88360 Global),10168299,CDM,0310,RC,88360,CPT,306,EAPG,,,,outpatient,facility,,,276.00,82.80,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo PD-L1 (88360 TC),10168300,CDM,0312,RC,88360,CPT,,,,,TC  ,outpatient,facility,,,210.00,63.00,96.60,210.0,,210.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,170.60,,,fee schedule,,,148.59,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,fee schedule,,,,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.06,,,fee schedule,,,,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,,96.60,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo PD-L1 (88360 TC),10168300,CDM,0312,RC,88360,CPT,05672,APC,,,TC  ,outpatient,facility,,,210.00,63.00,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo PD-L1 (88360 TC),10168300,CDM,0312,RC,88360,CPT,306,EAPG,,,TC  ,outpatient,facility,,,210.00,63.00,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FISH Auto Single Probe Initial (88367 Global),10168301,CDM,0310,RC,88367,CPT,,,,,,outpatient,facility,,,268.00,80.40,100.40,376.73,,204.19,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,152.36,,,fee schedule,,,222.31,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.40,,,fee schedule,,,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.07,,,fee schedule,,,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo FISH Auto Single Probe Initial (88367 Global),10168301,CDM,0310,RC,88367,CPT,05673,APC,,,,outpatient,facility,,,268.00,80.40,268.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,268.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,268.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo FISH Auto Single Probe Initial (88367 Global),10168301,CDM,0310,RC,88367,CPT,306,EAPG,,,,outpatient,facility,,,268.00,80.40,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FISH Auto Single Probe Addl (88373 Global),10168302,CDM,0310,RC,88373,CPT,,,,,,outpatient,facility,,,212.00,63.60,41.29,180.20,,111.45,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,83.16,,,fee schedule,,,135.20,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,54.48,,,fee schedule,,,,,,,,,159.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,64.07,,,fee schedule,,,,,,,,service not payable,159.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,180.20,,,percent of total billed charges,,,97.52,,,percent of total billed charges,,,,,,,,,46.83,,,fee schedule,,,,,,,,service not payable,,,,,,,41.29,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo FISH Auto Single Probe Addl (88373 Global),10168302,CDM,0310,RC,88373,CPT,305,EAPG,,,,outpatient,facility,,,212.00,63.60,46.86,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.08,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,91.39,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FISH Manual Single Probe Init (88368 Global),10168303,CDM,0310,RC,88368,CPT,,,,,,outpatient,facility,,,268.00,80.40,123.28,376.73,,191.95,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,143.23,,,fee schedule,,,277.62,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.08,,,fee schedule,,,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.86,,,fee schedule,,,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo FISH Manual Single Probe Init (88368 Global),10168303,CDM,0310,RC,88368,CPT,05673,APC,,,,outpatient,facility,,,268.00,80.40,268.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,268.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,268.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo FISH Manual Single Probe Init (88368 Global),10168303,CDM,0310,RC,88368,CPT,306,EAPG,,,,outpatient,facility,,,268.00,80.40,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo FISH Manual Single Probe Addl (88369 Global),10168304,CDM,0310,RC,88369,CPT,,,,,,outpatient,facility,,,212.00,63.60,91.47,238.27,,137.96,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,102.94,,,fee schedule,,,238.27,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.05,,,fee schedule,,,,,,,,,159.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.36,,,fee schedule,,,,,,,,service not payable,159.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,180.20,,,percent of total billed charges,,,97.52,,,percent of total billed charges,,,,,,,,,103.73,,,fee schedule,,,,,,,,service not payable,,,,,,,91.47,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo FISH Manual Single Probe Addl (88369 Global),10168304,CDM,0310,RC,88369,CPT,305,EAPG,,,,outpatient,facility,,,212.00,63.60,46.86,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.08,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,91.39,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo ER/PR (88361 TCx2),10168307,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,149.00,44.70,68.54,376.73,,149.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,149.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR (88361 TCx2),10168307,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,149.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,149.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo ER/PR (88361 TCx2),10168307,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo Her2 IHC (88361 TC),10168310,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,149.00,44.70,68.54,376.73,,149.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,149.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo Her2 IHC (88361 TC),10168310,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,149.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,149.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo Her2 IHC (88361 TC),10168310,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Spinal Muscular Atrophy (SMA) Copy Number Analysis,10170167,CDM,0310,RC,81329,CPT,,,,,,outpatient,facility,,,305.00,91.50,130.15,309.62,,188.49,,,percent of total billed charges,,,134.26,,,fee schedule,,,150.06,,,fee schedule,,,285.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,283.59,,,fee schedule,,,130.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",136.95,,,fee schedule,,,309.62,,,fee schedule,,,,,,,,,134.26,,,fee schedule,,,,,,,,,176.09,,,fee schedule,,,279.48,,,fee schedule,,,228.75,,,percent of total billed charges,,,134.26,,,fee schedule,,,130.15,,,fee schedule,,,136.95,,,fee schedule,,,207.09,,,fee schedule,,,134.26,,,fee schedule,,,228.75,,,percent of total billed charges,,,130.15,,,fee schedule,,,136.95,,,fee schedule,,,,,,,,,259.25,,,percent of total billed charges,,,140.30,,,percent of total billed charges,,,,,,,,,150.70,,,fee schedule,,,134.26,,,fee schedule,,,,,,,,,132.89,,,fee schedule,,,134.26,,,fee schedule,,,,,,,,,135.60,,,fee schedule,,,,,,,,
Spinal Muscular Atrophy (SMA) Copy Number Analysis,10170167,CDM,0310,RC,81329,CPT,386,EAPG,,,,outpatient,facility,,,305.00,91.50,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo KRAS/BRAF Mut (81275),10170343,CDM,0310,RC,81275,CPT,,,,,,outpatient,facility,,,384.00,115.20,176.64,436.74,,384.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,189.38,,,fee schedule,,,384.0,,,fee schedule,,,403.03,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,400.03,,,fee schedule,,,183.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",193.17,,,fee schedule,,,436.74,,,fee schedule,,,,,,,,,189.38,,,fee schedule,,,,,,,,,248.56,,,fee schedule,,,394.23,,,fee schedule,,,288.0,,,percent of total billed charges,,,189.38,,,fee schedule,,,183.59,,,fee schedule,,,193.17,,,fee schedule,,,292.31,,,fee schedule,,,189.38,,,fee schedule,,,288.0,,,percent of total billed charges,,,183.59,,,fee schedule,,,193.17,,,fee schedule,,,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,212.58,,,fee schedule,,,189.38,,,fee schedule,,,,,,,,,187.45,,,fee schedule,,,189.38,,,fee schedule,,,,,,,,,191.28,,,fee schedule,,,,,,,,
Neo KRAS/BRAF Mut (81275),10170343,CDM,0310,RC,81275,CPT,386,EAPG,,,,outpatient,facility,,,384.00,115.20,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo KRAS/BRAF Mut (81276),10170344,CDM,0310,RC,81276,CPT,,,,,,outpatient,facility,,,191.00,57.30,87.86,431.66,,118.04,,,percent of total billed charges,,,187.18,,,fee schedule,,,93.97,,,fee schedule,,,403.03,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,395.37,,,fee schedule,,,183.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",190.92,,,fee schedule,,,431.66,,,fee schedule,,,,,,,,,187.18,,,fee schedule,,,,,,,,,248.56,,,fee schedule,,,389.64,,,fee schedule,,,143.25,,,percent of total billed charges,,,187.18,,,fee schedule,,,183.59,,,fee schedule,,,190.92,,,fee schedule,,,292.31,,,fee schedule,,,187.18,,,fee schedule,,,143.25,,,percent of total billed charges,,,183.59,,,fee schedule,,,190.92,,,fee schedule,,,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,212.58,,,fee schedule,,,187.18,,,fee schedule,,,,,,,,,187.45,,,fee schedule,,,187.18,,,fee schedule,,,,,,,,,187.18,,,fee schedule,,,,,,,,
Neo KRAS/BRAF Mut (81276),10170344,CDM,0310,RC,81276,CPT,386,EAPG,,,,outpatient,facility,,,191.00,57.30,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo ER/PR (PR 88361),10170396,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,149.00,44.70,68.54,376.73,,149.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,149.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR (PR 88361),10170396,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,149.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,149.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo ER/PR (PR 88361),10170396,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,149.00,44.70,149.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,149.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo ER/PR/Her2Fish (PR 88361),10172109,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,156.00,46.80,71.76,376.73,,156.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,156.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.60,,,percent of total billed charges,,,71.76,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR/Her2Fish (PR 88361),10172109,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,156.00,46.80,156.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,156.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,156.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo ER/PR/Her2Fish (PR 88361),10172109,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,156.00,46.80,156.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM HUM COMP MICRO 7MM,10172126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MICRO 7MM,10172126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOOT NEUROTRANSMITTER WIRELESS,10172127,CDM,0274,RC,L8681,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOOT NEUROTRANSMITTER WIRELESS,10172127,CDM,0274,RC,L8681,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,3901.73,,,,,,,,1698.81,,,fee schedule,,,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,3573.71,,,fee schedule,,,,,,,,service not payable,1732.79,,,fee schedule,,,3901.73,,,fee schedule,,,,,,,,,1698.81,,,fee schedule,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,3521.92,,,fee schedule,,,1332.0,,,percent of total billed charges,,,1698.81,,,fee schedule,,,,,,,,service not payable,1732.79,,,fee schedule,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,1698.81,,,fee schedule,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,1732.79,,,fee schedule,,,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,1698.81,,,fee schedule,,,,,,,,,,,,,,,1698.81,,,fee schedule,,,,,,,,,1715.79,,,fee schedule,,,,,,,,
LENS TORIC IQ 19.5D X_SN6AT6 19.5 X_ALCON LAB INC,10172128,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TORIC IQ 19.5D X_SN6AT6 19.5 X_ALCON LAB INC,10172128,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HANDPIECE W/SUCT 10FT X_0210-100-000 X_STRYKER,10172130,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,951.00,285.30,368.99,808.35,,,,,,,,,,,,,,,,,,,,368.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,713.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,475.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.35,,,percent of total billed charges,,,427.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE W/SUCT 10FT X_0210-100-000 X_STRYKER,10172130,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,951.00,285.30,404.18,808.35,,,,,,,,,,,,,service not payable,,,,,,,479.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,404.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,713.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,475.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,713.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,808.35,,,percent of total billed charges,,,437.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo ER/PR/Her2Fish/Ki67 (PR 88361),10172140,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,156.00,46.80,71.76,376.73,,156.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,156.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.60,,,percent of total billed charges,,,71.76,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR/Her2Fish/Ki67 (PR 88361),10172140,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,156.00,46.80,156.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,156.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,156.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo ER/PR/Her2Fish/Ki67 (PR 88361),10172140,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,156.00,46.80,156.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo ER/PR/Her2Fish/Ki67 (Ki67 88361),10172141,CDM,0312,RC,88361,CPT,,,,,TC  ,outpatient,facility,,,156.00,46.80,71.76,376.73,,156.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,156.0,,,fee schedule,,,144.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,,fee schedule,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.61,,,fee schedule,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.60,,,percent of total billed charges,,,71.76,,,percent of total billed charges,,,,,,,,,376.73,,,fee schedule,,,,,,,,,,,,,,,332.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR/Her2Fish/Ki67 (Ki67 88361),10172141,CDM,0312,RC,88361,CPT,05673,APC,,,TC  ,outpatient,facility,,,156.00,46.80,156.0,792.29,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,725.68,,,fee schedule,,,156.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",351.86,,,fee schedule,,,792.29,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,715.16,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,330.88,,,fee schedule,,,351.86,,,fee schedule,,,,,,,,,344.96,,,fee schedule,,,,,,,,,156.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",351.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,,,,,,,344.96,,,fee schedule,,,,,,,,,348.40,,,fee schedule,,,,,,,,
Neo ER/PR/Her2Fish/Ki67 (Ki67 88361),10172141,CDM,0312,RC,88361,CPT,306,EAPG,,,TC  ,outpatient,facility,,,156.00,46.80,156.0,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,156.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo ER/PR/Her2Fish/Ki67 (Her2Fish 88374),10172142,CDM,0312,RC,88374,CPT,,,,,,outpatient,facility,,,476.00,142.80,157.86,588.09,,453.78,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,338.60,,,fee schedule,,,588.09,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.89,,,fee schedule,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,366.80,,,fee schedule,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.60,,,percent of total billed charges,,,218.96,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR/Her2Fish/Ki67 (Her2Fish 88374),10172142,CDM,0312,RC,88374,CPT,05672,APC,,,,outpatient,facility,,,476.00,142.80,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo ER/PR/Her2Fish/Ki67 (Her2Fish 88374),10172142,CDM,0312,RC,88374,CPT,306,EAPG,,,,outpatient,facility,,,476.00,142.80,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo ER/PR/Her2Fish (zHer2Fish 88374),10172221,CDM,0310,RC,88374,CPT,,,,,,outpatient,facility,,,476.00,142.80,157.86,588.09,,453.78,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,338.60,,,fee schedule,,,588.09,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.89,,,fee schedule,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,366.80,,,fee schedule,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.60,,,percent of total billed charges,,,218.96,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Neo ER/PR/Her2Fish (zHer2Fish 88374),10172221,CDM,0310,RC,88374,CPT,05672,APC,,,,outpatient,facility,,,476.00,142.80,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Neo ER/PR/Her2Fish (zHer2Fish 88374),10172221,CDM,0310,RC,88374,CPT,306,EAPG,,,,outpatient,facility,,,476.00,142.80,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PFL-Exercise test for bronchospasm includes Pre a,10174096,CDM,0460,RC,94617,CPT,,,,,,outpatient,facility,,,330.00,99.00,140.25,983.0,,203.94,,,percent of total billed charges,,,,,,,,,161.04,,,percent of total billed charges,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PFL-Exercise test for bronchospasm includes Pre a,10174096,CDM,0460,RC,94617,CPT,05734,APC,,,,outpatient,facility,,,330.00,99.00,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
PFL-Exercise test for bronchospasm includes Pre a,10174096,CDM,0460,RC,94617,CPT,412,EAPG,,,,outpatient,facility,,,330.00,99.00,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TENDON POST TIB 230X7.5MM X_41617000 FPOST.TIBIAL,10174112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3344.00,1003.20,1297.47,2842.40,,,,,,,,,,,,,,,,,,,,1297.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1421.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2508.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1672.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2842.40,,,percent of total billed charges,,,1504.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TENDON POST TIB 230X7.5MM X_41617000 FPOST.TIBIAL,10174112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3344.00,1003.20,1421.2,2842.40,,,,,,,,,,,,,service not payable,,,,,,,1686.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1421.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2508.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1672.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2508.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2842.40,,,percent of total billed charges,,,1538.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATIENT TRIAL KIT,10174113,CDM,0278,RC,C1820,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATIENT TRIAL KIT,10174113,CDM,0278,RC,C1820,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 10X58MM 135CM,10174114,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 10X58MM 135CM,10174114,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 6X16MM 135CM,10174115,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 6X16MM 135CM,10174115,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X37MM 135CM,10174116,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X37MM 135CM,10174116,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X26MM 135CM,10174117,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X26MM 135CM,10174117,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X16MM 135CM X_LSMU1350816 X_BARD,10174118,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X16MM 135CM X_LSMU1350816 X_BARD,10174118,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 6X58MM 135CM,10174119,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 6X58MM 135CM,10174119,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 6X58MM EXPAND X_LSMU0800658 X_BARD,10174120,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 6X58MM EXPAND X_LSMU0800658 X_BARD,10174120,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 6X37MM EXPAND,10174121,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 6X37MM EXPAND,10174121,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 6X26MM 80CM X_LSMU0800626 X_BARD,10174122,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 6X26MM 80CM X_LSMU0800626 X_BARD,10174122,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 6X16MM 80CM,10174123,CDM,0279,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3204.5,6409.0,,4659.72,,,percent of total billed charges,,,,,,,,service not payable,3679.52,,,percent of total billed charges,,,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,4901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 5X37MM 80CM,10174124,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 5X37MM 80CM,10174124,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 5X26MM 80CM X_LSMU0800526 X_BARD,10174125,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 5X26MM 80CM X_LSMU0800526 X_BARD,10174125,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 5X12MM EXPAND X_LSMU0801258 X_BARD,10174126,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 5X12MM EXPAND X_LSMU0801258 X_BARD,10174126,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 10X58MM 80CM,10174127,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 10X58MM 80CM,10174127,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 10X38MM 80CM,10174128,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 10X38MM 80CM,10174128,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X58MM 80CM X_LSMU0800858 X_BARD,10174129,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X58MM 80CM X_LSMU0800858 X_BARD,10174129,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X37MM 80CM,10174130,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X37MM 80CM,10174130,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X26MM 80CM,10174131,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X26MM 80CM,10174131,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC CATH 8X16MM EXPAND,10174132,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC CATH 8X16MM EXPAND,10174132,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP HEX 20X6.5MM 3.5MM,10176111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,437.00,131.10,169.56,371.45,,,,,,,,,,,,,,,,,,,,169.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,196.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP HEX 20X6.5MM 3.5MM,10176111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,,,,,,,,,,,,service not payable,,,,,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert Elect Ven System Prev,1017669,CDM,0481,RC,33224,CPT,,,,,,outpatient,facility,,,19985.00,5995.50,4917.20,28801.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,10080.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,14988.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,14988.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16987.25,,,percent of total billed charges,,,9193.10,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert Elect Ven System Prev,1017669,CDM,0481,RC,33224,CPT,05223,APC,,,,outpatient,facility,,,19985.00,5995.50,9626.29,23049.94,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,21112.12,,,fee schedule,,,9626.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10229.20,,,fee schedule,,,23049.94,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,20806.14,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,9626.29,,,fee schedule,,,10229.20,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,9626.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",10229.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,10128.58,,,fee schedule,,,,,,,,
Insert Elect Ven System Prev,1017669,CDM,0481,RC,33224,CPT,86,EAPG,,,,outpatient,facility,,,19985.00,5995.50,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HEAD GLBL UNITE ECC 52X15MM,10178098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLBL UNITE ECC 52X15MM,10178098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DR LFT 14H LNG X_54-25677 X_STRYKER ORTHOPAE,10178099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3783.00,1134.90,1467.80,3215.55,,,,,,,,,,,,,,,,,,,,1467.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1607.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2837.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3215.55,,,percent of total billed charges,,,1702.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DR LFT 14H LNG X_54-25677 X_STRYKER ORTHOPAE,10178099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3783.00,1134.90,1607.77,3215.55,,,,,,,,,,,,,service not payable,,,,,,,1908.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1607.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2837.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1891.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2837.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3215.55,,,percent of total billed charges,,,1740.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FT 2.4X16MM X_656116 X_STRYKER ORTHOPAE,10178100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FT 2.4X16MM X_656116 X_STRYKER ORTHOPAE,10178100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE DRILL BONE GEMINUS 1.5MM,10178101,CDM,0278,RC,C1769,HCPCS,,,,,,inpatient,facility,,,197.00,59.10,76.44,167.45,,,,,,,,,,,,,,,,,,,,76.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,147.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,,88.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE DRILL BONE GEMINUS 1.5MM,10178101,CDM,0278,RC,C1769,HCPCS,,,,,,outpatient,facility,,,197.00,59.10,83.72,167.45,,,,,,,,,,,,,service not payable,,,,,,,99.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,83.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,147.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,98.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,147.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,,90.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NONLOCK 12X3.5MM,10178102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NONLOCK 12X3.5MM,10178102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LOCKING SMOOTH 18X2.0MM,10178107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LOCKING SMOOTH 18X2.0MM,10178107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LOCKING SMOOTH 20X2.0MM,10178108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LOCKING SMOOTH 20X2.0MM,10178108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG HCOMP 2.7X22MM X_HCLP-27220-TS X_SLELETAL,10178109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG HCOMP 2.7X22MM X_HCLP-27220-TS X_SLELETAL,10178109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG HCOMP 2.7X21MM X_HCLP-27210-TS X_SLELETAL,10178110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG HCOMP 2.7X21MM X_HCLP-27210-TS X_SLELETAL,10178110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LOCKING THREADED 20X2.3MM,10178111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LOCKING THREADED 20X2.3MM,10178111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG THRD 2.3X21MM X_TPLS-23210-TS X_SKELETAL,10178112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG THRD 2.3X21MM X_TPLS-23210-TS X_SKELETAL,10178112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST RAD WD 4H LFT X_GMN-LTW-4HL X_SKELETAL,10178113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST RAD WD 4H LFT X_GMN-LTW-4HL X_SKELETAL,10178113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cortisol Level,1018,CDM,0300,RC,82533,CPT,,,,,,outpatient,facility,,,131.00,39.30,15.49,111.35,,57.21,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,15.97,,,fee schedule,,,42.69,,,fee schedule,,,34.0,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,33.74,,,fee schedule,,,15.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.29,,,fee schedule,,,36.84,,,fee schedule,,,,,,,,,15.97,,,fee schedule,,,,,,,,,21.06,,,fee schedule,,,33.25,,,fee schedule,,,98.25,,,percent of total billed charges,,,15.97,,,fee schedule,,,15.49,,,fee schedule,,,16.29,,,fee schedule,,,24.77,,,fee schedule,,,15.97,,,fee schedule,,,98.25,,,percent of total billed charges,,,,,,,,,16.29,,,fee schedule,,,,,,,,,111.35,,,percent of total billed charges,,,60.26,,,percent of total billed charges,,,,,,,,,17.93,,,fee schedule,,,15.97,,,fee schedule,,,,,,,,,15.81,,,fee schedule,,,15.97,,,fee schedule,,,,,,,,,16.13,,,fee schedule,,,,,,,,
Cortisol Level,1018,CDM,0300,RC,82533,CPT,398,EAPG,,,,outpatient,facility,,,131.00,39.30,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT PROLAYER 4X4CM X_3102-26944 X_STRYKER ORTHOP,10182097,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROLAYER 4X4CM X_3102-26944 X_STRYKER ORTHOP,10182097,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PCL,10182099,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PCL,10182099,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK RE 2.50X6.0MM 5F,10182100,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 COLLARLESS SZ9,10182104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 COLLARLESS SZ9,10182104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA SZ1.5 17.5MM,10182105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA SZ1.5 17.5MM,10182105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RADIUS HEX POST 5.5X600MM,10182106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RADIUS HEX POST 5.5X600MM,10182106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR CROSSLINK 35-44MM X_48236035 X_STRYKER,10182107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR CROSSLINK 35-44MM X_48236035 X_STRYKER,10182107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PEEK 4D 10X20X11MM,10182108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PEEK 4D 10X20X11MM,10182108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.0X50MM X_482316050 X_STRYKER,10182109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2732.00,819.60,1060.02,2322.20,,,,,,,,,,,,,,,,,,,,1060.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322.20,,,percent of total billed charges,,,1229.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.0X50MM X_482316050 X_STRYKER,10182109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2732.00,819.60,1161.10,2322.20,,,,,,,,,,,,,service not payable,,,,,,,1378.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2322.20,,,percent of total billed charges,,,1256.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.0X45MM X_482316045 X_STRYKER,10182110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2732.00,819.60,1060.02,2322.20,,,,,,,,,,,,,,,,,,,,1060.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322.20,,,percent of total billed charges,,,1229.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.0X45MM X_482316045 X_STRYKER,10182110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2732.00,819.60,1161.10,2322.20,,,,,,,,,,,,,service not payable,,,,,,,1378.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2322.20,,,percent of total billed charges,,,1256.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 5.0X40MM X_482315040 X_STRYKER,10182111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2732.00,819.60,1060.02,2322.20,,,,,,,,,,,,,,,,,,,,1060.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322.20,,,percent of total billed charges,,,1229.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5.0X40MM X_482315040 X_STRYKER,10182111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2732.00,819.60,1161.10,2322.20,,,,,,,,,,,,,service not payable,,,,,,,1378.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2322.20,,,percent of total billed charges,,,1256.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM VEGA SZ3 RT X_NX028Z X_B BRAUN MEDICAL,10182112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM VEGA SZ3 RT X_NX028Z X_B BRAUN MEDICAL,10182112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 COLLARLESS SZ8,10182113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 COLLARLESS SZ8,10182113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X20MM X_285220SND X_INTEGRA LIFE,10182114,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X20MM X_285220SND X_INTEGRA LIFE,10182114,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6X39MM VASC VBX 135CM,10182115,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6X39MM VASC VBX 135CM,10182115,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT AAA 20F 2X30X94MM,10182116,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24041.00,7212.30,9327.91,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9327.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20434.85,,,percent of total billed charges,,,10818.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT AAA 20F 2X30X94MM,10182116,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24041.00,7212.30,10097.22,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12126.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20434.85,,,percent of total billed charges,,,11058.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 10X20X130,10182117,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT DISTAL AAA ZE 12X28X76MM,10182118,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,12157.00,3647.10,4716.92,10333.45,,5956.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5105.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4716.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5166.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9117.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6078.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10333.45,,,percent of total billed charges,,,5470.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT DISTAL AAA ZE 12X28X76MM,10182118,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,12157.00,3647.10,5105.94,10333.45,,5956.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5105.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6131.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5166.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9117.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6078.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9117.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10333.45,,,percent of total billed charges,,,5592.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD NEURO SPINAL 2X8X50CM,10182330,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD NEURO SPINAL 2X8X50CM,10182330,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT TIBIAL CONE SZ E R M/LL X_5549-A-252 X_STR,10182332,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14062.00,4218.60,5456.06,11952.70,,6890.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5906.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5456.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5976.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10546.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7031.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11952.70,,,percent of total billed charges,,,6327.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT TIBIAL CONE SZ E R M/LL X_5549-A-252 X_STR,10182332,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14062.00,4218.60,5906.04,11952.70,,6890.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5906.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7092.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5976.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10546.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7031.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10546.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11952.70,,,percent of total billed charges,,,6468.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ 4.0 22.5MM,10182333,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ 4.0 22.5MM,10182333,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 22.0 X_MTA3U0-22.0 X_ALCON LAB INC,10182336,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 22.0 X_MTA3U0-22.0 X_ALCON LAB INC,10182336,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EXT GUIDEZILLA II 6F LONG,10182339,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,1333.64,,,percent of total billed charges,,,,,,,,service not payable,1053.10,,,percent of total billed charges,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW INTRAFIX ADVANCE 8X30,10182340,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW INTRAFIX ADVANCE 8X30,10182340,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10184114,CDM,0320,RC,75901,CPT,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,443.74,,,fee schedule,,Paid in addition to outpatient services ,,,,,,service not payable,322.64,,,fee schedule,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10184114,CDM,0320,RC,75901,CPT,474,EAPG,,,,outpatient,facility,,,546.00,163.80,294.16,697.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,592.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,436.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,480.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CONNECTOR 4H ARMADA ASF X_8452446 X_NUVASIVE,10184133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR 4H ARMADA ASF X_8452446 X_NUVASIVE,10184133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR 2H ARMADA ASF X_8452426 X_NUVASIVE,10184134,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR 2H ARMADA ASF X_8452426 X_NUVASIVE,10184134,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SIDE 5.5 ASF ARMADA X_8452156 X_NUVASIVE,10184135,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5233.00,1569.90,2030.40,4448.05,,2564.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2197.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2030.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2224.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3924.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4448.05,,,percent of total billed charges,,,2354.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SIDE 5.5 ASF ARMADA X_8452156 X_NUVASIVE,10184135,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5233.00,1569.90,2197.86,4448.05,,2564.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2197.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2639.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2224.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3924.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2616.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3924.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4448.05,,,percent of total billed charges,,,2407.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SIDE 6.35 ASF ARMADA X_8452152 X_NUVASIV,10184136,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5233.00,1569.90,2030.40,4448.05,,2564.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2197.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2030.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2224.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3924.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4448.05,,,percent of total billed charges,,,2354.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SIDE 6.35 ASF ARMADA X_8452152 X_NUVASIV,10184136,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5233.00,1569.90,2197.86,4448.05,,2564.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2197.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2639.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2224.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3924.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2616.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3924.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4448.05,,,percent of total billed charges,,,2407.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROCEDURE KIT 36.5MM 1.8MM MSP,10184137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCEDURE KIT 36.5MM 1.8MM MSP,10184137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.4X12MM MSP CORTICAL NL,10184138,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.4X12MM MSP CORTICAL NL,10184138,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.4MM 10MM MSP LOCK,10184139,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.4MM 10MM MSP LOCK,10184139,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FOREFOOT IB IMPLANT SYSTEM,10184140,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4574.00,1372.20,1774.71,3887.90,,,,,,,,,,,,,,,,,,,,1774.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.90,,,percent of total billed charges,,,2058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOREFOOT IB IMPLANT SYSTEM,10184140,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,,,,,,,,,,,,service not payable,,,,,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE FLOPPY TIP 0.035X180CM,10184147,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,117.00,35.10,49.73,99.45,,72.31,,,percent of total billed charges,,,,,,,,service not payable,57.10,,,percent of total billed charges,,,59.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,49.73,,,percent of total billed charges,,,,,,,,,87.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,58.5,,,percent of total billed charges,,,,,,,,service not payable,87.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,99.45,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,76.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,76.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHBG,10186105,CDM,0300,RC,84270,CPT,,,,,,outpatient,facility,,,99.00,29.70,20.64,92.37,,92.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,21.30,,,fee schedule,,,68.92,,,fee schedule,,,45.32,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,44.98,,,fee schedule,,,20.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.73,,,fee schedule,,,49.11,,,fee schedule,,,,,,,,,21.30,,,fee schedule,,,,,,,,,27.81,,,fee schedule,,,44.33,,,fee schedule,,,74.25,,,percent of total billed charges,,,21.30,,,fee schedule,,,20.64,,,fee schedule,,,21.73,,,fee schedule,,,32.70,,,fee schedule,,,21.30,,,fee schedule,,,74.25,,,percent of total billed charges,,,,,,,,,21.73,,,fee schedule,,,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,23.90,,,fee schedule,,,21.30,,,fee schedule,,,,,,,,,21.08,,,fee schedule,,,21.30,,,fee schedule,,,,,,,,,21.51,,,fee schedule,,,,,,,,
SHBG,10186105,CDM,0300,RC,84270,CPT,400,EAPG,,,,outpatient,facility,,,99.00,29.70,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Testosterone Total and Free (Adult Male),10186106,CDM,0300,RC,84403,CPT,,,,,,outpatient,facility,,,67.00,20.10,24.52,67.0,,67.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,25.29,,,fee schedule,,,67.0,,,fee schedule,,,53.83,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,53.43,,,fee schedule,,,24.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",25.80,,,fee schedule,,,58.33,,,fee schedule,,,,,,,,,25.29,,,fee schedule,,,,,,,,,33.28,,,fee schedule,,,52.65,,,fee schedule,,,50.25,,,percent of total billed charges,,,25.29,,,fee schedule,,,24.52,,,fee schedule,,,25.80,,,fee schedule,,,39.14,,,fee schedule,,,25.29,,,fee schedule,,,50.25,,,percent of total billed charges,,,,,,,,,25.80,,,fee schedule,,,,,,,,,56.95,,,percent of total billed charges,,,30.82,,,percent of total billed charges,,,,,,,,,28.39,,,fee schedule,,,25.29,,,fee schedule,,,,,,,,,25.04,,,fee schedule,,,25.29,,,fee schedule,,,,,,,,,25.55,,,fee schedule,,,,,,,,
Testosterone Total and Free (Adult Male),10186106,CDM,0300,RC,84403,CPT,398,EAPG,,,,outpatient,facility,,,67.00,20.10,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Testosterone Albumin,10186107,CDM,0300,RC,82040,CPT,,,,,,outpatient,facility,,,36.00,10.80,4.70,30.60,,21.02,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.85,,,fee schedule,,,15.68,,,fee schedule,,,10.32,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,10.25,,,fee schedule,,,4.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.95,,,fee schedule,,,11.19,,,fee schedule,,,,,,,,,4.85,,,fee schedule,,,,,,,,,6.31,,,fee schedule,,,10.1,,,fee schedule,,,27.0,,,percent of total billed charges,,,4.85,,,fee schedule,,,4.70,,,fee schedule,,,4.95,,,fee schedule,,,7.43,,,fee schedule,,,4.85,,,fee schedule,,,27.0,,,percent of total billed charges,,,,,,,,,4.95,,,fee schedule,,,,,,,,,30.60,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,5.45,,,fee schedule,,,4.85,,,fee schedule,,,,,,,,,4.80,,,fee schedule,,,4.85,,,fee schedule,,,,,,,,,4.90,,,fee schedule,,,,,,,,
Testosterone Albumin,10186107,CDM,0300,RC,82040,CPT,402,EAPG,,,,outpatient,facility,,,36.00,10.80,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANN TI LP 3X22MM,10186118,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI LP 3X22MM,10186118,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE W/DBL TRCR TIP .045X6.84 X_AR-8950-06 X_,10186119,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,132.00,39.60,56.10,112.2,,81.58,,,percent of total billed charges,,,,,,,,service not payable,64.42,,,percent of total billed charges,,,66.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,,,,,,,99.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,66.0,,,percent of total billed charges,,,,,,,,service not payable,99.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,112.2,,,percent of total billed charges,,,60.72,,,percent of total billed charges,,,,,,,,,85.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,85.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PT CANN 50MM X_7182-8150 X_SMITH NEPHEW,10186120,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PT CANN 50MM X_7182-8150 X_SMITH NEPHEW,10186120,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,139.40,,,,,,,,,,,,,service not payable,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PT CANN 60MM X_7182-8160 X_SMITH NEPHEW,10186121,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PT CANN 60MM X_7182-8160 X_SMITH NEPHEW,10186121,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,139.40,,,,,,,,,,,,,service not payable,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIX PL 13X6MM 19.0 DIO X_ZLB00-19.0 X_PREC,10186123,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIX PL 13X6MM 19.0 DIO X_ZLB00-19.0 X_PREC,10186123,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1956.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1956.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,service not payable,1760.40,,,fee schedule,,,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE ULTRA HP 700CC,10186124,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE ULTRA HP 700CC,10186124,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Myocardial Contrast Perfusion Echo at rest or w/s,10188108,CDM,0480,RC,0439T,CPT,,,,,,outpatient,facility,,,493.00,147.90,209.53,2075.0,,304.67,,,percent of total billed charges,,,,,,,,service not payable,240.58,,,percent of total billed charges,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,246.5,,,percent of total billed charges,,,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,2075.0,,,per diem,,,,,,,,service not payable,,,,,,,1826.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Myocardial Contrast Perfusion Echo at rest or w/s,10188108,CDM,0480,RC,0439T,CPT,81,EAPG,,,,outpatient,facility,,,493.00,147.90,493.0,1789.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1789.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1520.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,493.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,493.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1051.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1156.67,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR CLIK 0.79X0.22X0.25IN,10188153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR CLIK 0.79X0.22X0.25IN,10188153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X38MM X_222838 X_SMITH NEPHEW,10188154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X38MM X_222838 X_SMITH NEPHEW,10188154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 8X14X40 X_5284402 X_NUVASIVE,10188156,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 8X14X40 X_5284402 X_NUVASIVE,10188156,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Influenza A and B Screen PCR,101892,CDM,0300,RC,87502,CPT,,,,,,outpatient,facility,,,1016.00,304.80,91.01,863.60,,361.60,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,93.88,,,fee schedule,,,269.81,,,fee schedule,,,199.79,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,198.31,,,fee schedule,,,91.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.76,,,fee schedule,,,216.51,,,fee schedule,,,,,,,,,93.88,,,fee schedule,,,,,,,,,123.44,,,fee schedule,,,195.43,,,fee schedule,,,762.0,,,percent of total billed charges,,,93.88,,,fee schedule,,,91.01,,,fee schedule,,,95.76,,,fee schedule,,,145.17,,,fee schedule,,,93.88,,,fee schedule,,,762.0,,,percent of total billed charges,,,,,,,,,95.76,,,fee schedule,,,,,,,,,863.60,,,percent of total billed charges,,,467.36,,,percent of total billed charges,,,,,,,,,105.38,,,fee schedule,,,93.88,,,fee schedule,,,,,,,,,92.93,,,fee schedule,,,93.88,,,fee schedule,,,,,,,,,94.82,,,fee schedule,,,,,,,,
Influenza A and B Screen PCR,101892,CDM,0300,RC,87502,CPT,388,EAPG,,,,outpatient,facility,,,1016.00,304.80,202.12,322.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,273.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,202.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,222.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Rhinoplasty primary,10190123,CDM,0450,RC,30400,CPT,,,,,,outpatient,facility,,,10162.00,3048.60,774.0,8637.70,,6280.12,,,percent of total billed charges,,,,,,,,,4959.06,,,percent of total billed charges,,,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Rhinoplasty primary,10190123,CDM,0450,RC,30400,CPT,05165,APC,,,,outpatient,facility,,,10162.00,3048.60,2720.69,13029.28,,,,,,,,5672.93,,,fee schedule,,,,,,,,,,,,,,,11933.90,,,fee schedule,,,2720.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",5786.39,,,fee schedule,,,13029.28,,,fee schedule,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,,,,,,,11760.95,,,fee schedule,,,,,,,,,5672.93,,,fee schedule,,,2720.69,,,fee schedule,,,5786.39,,,fee schedule,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,2720.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",5786.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,5729.42,,,fee schedule,,,,,,,,
Rhinoplasty primary,10190123,CDM,0450,RC,30400,CPT,227,EAPG,,,,outpatient,facility,,,10162.00,3048.60,3803.52,9594.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9594.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8155.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3803.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3803.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3803.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4650.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5115.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPACER PEEK AVS 4D 10X30MM,10190277,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 10X30MM,10190277,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BLN LUT 5F 4MMX75CM X_LX35754405F X_BARD,10190278,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB INFINITY SZ5,10190279,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18361.00,5508.30,7124.07,15606.85,,8996.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7711.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7124.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13770.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15606.85,,,percent of total billed charges,,,8262.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB INFINITY SZ5,10190279,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18361.00,5508.30,7711.62,15606.85,,8996.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7711.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9261.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7803.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13770.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13770.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15606.85,,,percent of total billed charges,,,8446.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DOME TALAR INBONE SZ4 SULCUS X_220220904 X_WRIGHT,10190280,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15883.00,4764.90,6162.60,13500.55,,7782.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6670.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6162.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6750.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7941.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13500.55,,,percent of total billed charges,,,7147.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOME TALAR INBONE SZ4 SULCUS X_220220904 X_WRIGHT,10190280,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15883.00,4764.90,6670.86,13500.55,,7782.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6670.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8011.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6750.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7941.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11912.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13500.55,,,percent of total billed charges,,,7306.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT INFINITY POLY SZ4 X_33655409 X_WRIGHT MEDIC,10190281,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT INFINITY POLY SZ4 X_33655409 X_WRIGHT MEDIC,10190281,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FUSION CERVICAL 16X14X7 X_1000-00-0716 X_NU,10190282,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FUSION CERVICAL 16X14X7 X_1000-00-0716 X_NU,10190282,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB REV ROTATING CEM SZ4,10190283,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17663.00,5298.90,6853.24,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6853.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15013.55,,,percent of total billed charges,,,7948.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB REV ROTATING CEM SZ4,10190283,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17663.00,5298.90,7418.46,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8909.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15013.55,,,percent of total billed charges,,,8124.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB PRESSFIT STR 12X110MM,10190284,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB PRESSFIT STR 12X110MM,10190284,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATUN TIB SLV M/L 37MM FULL POR,10190285,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12992.00,3897.60,5040.90,11043.20,,6366.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5456.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5040.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5521.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9744.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6496.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11043.20,,,percent of total billed charges,,,5846.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATUN TIB SLV M/L 37MM FULL POR,10190285,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12992.00,3897.60,5456.64,11043.20,,6366.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5456.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6553.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5521.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9744.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6496.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9744.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11043.20,,,percent of total billed charges,,,5976.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ5 10MM,10190286,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ5 10MM,10190286,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INFUS CRAGGMCNAMAR 20X135,10190287,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE ENDOANCHOR 16F 22MMX62CM,10190288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5773.00,1731.90,2239.92,4907.05,,2828.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2424.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2239.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2453.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4329.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2886.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4907.05,,,percent of total billed charges,,,2597.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE ENDOANCHOR 16F 22MMX62CM,10190288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5773.00,1731.90,2424.66,4907.05,,2828.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2424.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2911.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2453.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4329.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2886.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4329.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4907.05,,,percent of total billed charges,,,2655.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE BIOSYNC ANATOM 20X6.5MM,10190289,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7196.00,2158.80,2792.05,6116.60,,3526.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3022.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2792.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5397.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3598.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6116.60,,,percent of total billed charges,,,3238.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE BIOSYNC ANATOM 20X6.5MM,10190289,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7196.00,2158.80,3022.32,6116.60,,3526.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3022.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3629.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3058.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5397.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3598.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5397.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6116.60,,,percent of total billed charges,,,3310.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE BIOSYNC 20X20X12MM X_AR-8942W-2012 X_ARTHREX,10190290,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE BIOSYNC 20X20X12MM X_AR-8942W-2012 X_ARTHREX,10190290,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY EXPS 7FR 10X57MM,10190291,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3896.00,1168.80,1511.65,3311.60,,,,,,,,,,,,,,,,,,,,1511.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1655.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2922.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1948.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3311.60,,,percent of total billed charges,,,1753.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY EXPS 7FR 10X57MM,10190291,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3896.00,1168.80,1655.8,3311.60,,,,,,,,,,,,,service not payable,,,,,,,1965.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1655.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2922.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1948.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2922.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3311.60,,,percent of total billed charges,,,1792.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT ENDURANT II BIF X_ETBF2516C124E X_MEDT,10190292,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,29430.00,8829.00,11418.84,25015.5,,14420.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12360.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11418.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12507.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22072.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14715.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25015.5,,,percent of total billed charges,,,13243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT ENDURANT II BIF X_ETBF2516C124E X_MEDT,10190292,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,29430.00,8829.00,12360.6,25015.5,,14420.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12360.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14844.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12507.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14715.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22072.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,25015.5,,,percent of total billed charges,,,13537.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SHEATH TOURGUIDE6.5F 17MM,10190293,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHAMBER L 12.5 21.5 X_S122UV-21.5 X_BAUSC,10190294,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHAMBER L 12.5 21.5 X_S122UV-21.5 X_BAUSC,10190294,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DOWEL CANCELOUS 10X25MM,10190295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOWEL CANCELOUS 10X25MM,10190295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6.5X85MM X_341085 X_STRYKER ORTHOPAEDIC,10192127,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,190.00,57.00,73.72,161.5,,,,,,,,,,,,,,,,,,,,73.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,142.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.5,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6.5X85MM X_341085 X_STRYKER ORTHOPAEDIC,10192127,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,190.00,57.00,80.75,161.5,,,,,,,,,,,,,service not payable,,,,,,,95.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,142.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,142.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,161.5,,,percent of total billed charges,,,87.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
T-PLATE VARIAX FOOT X_40-15081 X_STRYKER ORTHOPAED,10192128,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1910.00,573.00,741.08,1623.5,,,,,,,,,,,,,,,,,,,,741.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,811.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1432.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1623.5,,,percent of total billed charges,,,859.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
T-PLATE VARIAX FOOT X_40-15081 X_STRYKER ORTHOPAED,10192128,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1910.00,573.00,811.75,1623.5,,,,,,,,,,,,,service not payable,,,,,,,963.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,811.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1432.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1432.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1623.5,,,percent of total billed charges,,,878.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CEMENTLESS SZ7,10192130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CEMENTLESS SZ7,10192130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS 5.5X12.5MM 23.5 ANT CHAMB X_MTA3U0-23.5 X_ALC,10192131,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS 5.5X12.5MM 23.5 ANT CHAMB X_MTA3U0-23.5 X_ALC,10192131,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO FEM LEFT 3 5FX100CM,10192132,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,61.00,18.30,25.93,51.85,,37.70,,,percent of total billed charges,,,,,,,,service not payable,29.77,,,percent of total billed charges,,,30.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25.93,,,percent of total billed charges,,,,,,,,,45.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30.5,,,percent of total billed charges,,,,,,,,service not payable,45.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51.85,,,percent of total billed charges,,,28.06,,,percent of total billed charges,,,,,,,,,39.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,39.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP MICRO ANEURYSM SUNDT SZ3 X_20-1803 X_CODMAN,10192134,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2736.00,820.80,1061.57,2325.60,,,,,,,,,,,,,,,,,,,,1061.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1162.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2052.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1368.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.60,,,percent of total billed charges,,,1231.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP MICRO ANEURYSM SUNDT SZ3 X_20-1803 X_CODMAN,10192134,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2736.00,820.80,1162.8,2325.60,,,,,,,,,,,,,service not payable,,,,,,,1380.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1162.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2052.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1368.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2052.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2325.60,,,percent of total billed charges,,,1258.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS UV TORIC ASPHERIC 12.5D,10192135,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS UV TORIC ASPHERIC 12.5D,10192135,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING SACRUM BRDR 9.2X9.2IN  X_282455  X_353788,10192274,CDM,0623,RC,A6213,HCPCS,,,,,,outpatient,facility,,,74.00,22.20,31.45,62.90,,45.73,,,percent of total billed charges,,,,,,,,service not payable,36.11,,,percent of total billed charges,,,37.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,31.45,,,percent of total billed charges,,,,,,,,,55.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,37.0,,,percent of total billed charges,,,,,,,,service not payable,55.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,,34.04,,,percent of total billed charges,,,,,,,,,48.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,48.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 8H MINI REG X_25-550-08-1 X_KLS MARTIN L P,10192281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,443.00,132.90,171.88,376.55,,,,,,,,,,,,,,,,,,,,171.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,332.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,221.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,376.55,,,percent of total billed charges,,,199.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 8H MINI REG X_25-550-08-1 X_KLS MARTIN L P,10192281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,443.00,132.90,188.28,376.55,,,,,,,,,,,,,service not payable,,,,,,,223.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,188.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,332.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,221.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,332.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,376.55,,,percent of total billed charges,,,203.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR OC LONG OFFSET X_7755327 X_MEDTRONIC,10192282,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2278.00,683.40,883.86,1936.3,,,,,,,,,,,,,,,,,,,,883.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,968.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1708.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1139.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1936.3,,,percent of total billed charges,,,1025.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR OC LONG OFFSET X_7755327 X_MEDTRONIC,10192282,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2278.00,683.40,968.15,1936.3,,,,,,,,,,,,,service not payable,,,,,,,1149.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,968.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1708.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1139.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1708.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1936.3,,,percent of total billed charges,,,1047.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW OC 5X12MM X_7750612 X_MEDTRONIC,10192283,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1141.00,342.30,442.71,969.85,,,,,,,,,,,,,,,,,,,,442.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,855.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,570.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,969.85,,,percent of total billed charges,,,513.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW OC 5X12MM X_7750612 X_MEDTRONIC,10192283,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1141.00,342.30,484.93,969.85,,,,,,,,,,,,,service not payable,,,,,,,575.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,484.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,855.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,570.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,855.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,969.85,,,percent of total billed charges,,,524.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ZEVO 21MM X_3001021 X_MEDTRONIC,10192284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ZEVO 21MM X_3001021 X_MEDTRONIC,10192284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ZEVO SELF DRILLING 4.0X15MM X_7714015 X_MEDT,10192285,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ZEVO SELF DRILLING 4.0X15MM X_7714015 X_MEDT,10192285,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ZEVO SELF DRILLING 3.5X13MM X_7713513 X_MEDT,10192286,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ZEVO SELF DRILLING 3.5X13MM X_7713513 X_MEDT,10192286,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7X65MM X_7112-9065 X_SMITH NEPHEW,10192287,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7X65MM X_7112-9065 X_SMITH NEPHEW,10192287,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7X80MM X_7112-9080 X_SMITH NEPHEW,10192288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7X80MM X_7112-9080 X_SMITH NEPHEW,10192288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COR 7FRX25CM GUIDEZILLA I,10192290,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,1333.64,,,percent of total billed charges,,,,,,,,service not payable,1053.10,,,percent of total billed charges,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
E Test KB,101936,CDM,0300,RC,87184,CPT,,,,,,outpatient,facility,,,86.00,25.80,7.11,73.10,,29.32,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.33,,,fee schedule,,,21.88,,,fee schedule,,,15.6,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,15.48,,,fee schedule,,,7.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.48,,,fee schedule,,,16.90,,,fee schedule,,,,,,,,,7.33,,,fee schedule,,,,,,,,,9.69,,,fee schedule,,,15.26,,,fee schedule,,,64.5,,,percent of total billed charges,,,7.33,,,fee schedule,,,7.11,,,fee schedule,,,7.48,,,fee schedule,,,11.4,,,fee schedule,,,7.33,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,7.48,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,8.23,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.26,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.40,,,fee schedule,,,,,,,,
E Test KB,101936,CDM,0300,RC,87184,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
E Test MIC,101937,CDM,0300,RC,87181,CPT,,,,,,outpatient,facility,,,86.00,25.80,4.51,73.10,,20.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.65,,,fee schedule,,,15.05,,,fee schedule,,,9.90,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,9.83,,,fee schedule,,,4.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.74,,,fee schedule,,,10.73,,,fee schedule,,,,,,,,,4.65,,,fee schedule,,,,,,,,,6.31,,,fee schedule,,,9.69,,,fee schedule,,,64.5,,,percent of total billed charges,,,4.65,,,fee schedule,,,4.51,,,fee schedule,,,4.74,,,fee schedule,,,7.43,,,fee schedule,,,4.65,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,4.74,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,5.23,,,fee schedule,,,4.65,,,fee schedule,,,,,,,,,4.61,,,fee schedule,,,4.65,,,fee schedule,,,,,,,,,4.70,,,fee schedule,,,,,,,,
E Test MIC,101937,CDM,0300,RC,87181,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW MOUNTAINER 3.5X26MM,1019519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3871.00,1161.30,1501.95,3290.35,,,,,,,,,,,,,,,,,,,,1501.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1645.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3290.35,,,percent of total billed charges,,,1741.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MOUNTAINER 3.5X26MM,1019519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3871.00,1161.30,1645.18,3290.35,,,,,,,,,,,,,service not payable,,,,,,,1952.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1645.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3290.35,,,percent of total billed charges,,,1780.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TROCAR WIRE SINGLE 1.6X150MM,1019521,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,137.00,41.10,53.16,116.45,,,,,,,,,,,,,,,,,,,,53.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,61.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TROCAR WIRE SINGLE 1.6X150MM,1019521,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,137.00,41.10,58.23,116.45,,,,,,,,,,,,,service not payable,,,,,,,69.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,102.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BAR CLAMP JET X_71062019 X_RICHARDS MFG CO,1019522,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2216.00,664.80,859.81,1883.60,,,,,,,,,,,,,,,,,,,,859.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,941.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1108.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1883.60,,,percent of total billed charges,,,997.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BAR CLAMP JET X_71062019 X_RICHARDS MFG CO,1019522,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2216.00,664.80,941.80,1883.60,,,,,,,,,,,,,service not payable,,,,,,,1117.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,941.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1108.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1662.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1883.60,,,percent of total billed charges,,,1019.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 3.5X24MM X_71149524 X_RICHARDS MFG CO,1019523,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,158.00,47.40,61.30,134.30,,,,,,,,,,,,,,,,,,,,61.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,118.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.30,,,percent of total billed charges,,,71.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 3.5X24MM X_71149524 X_RICHARDS MFG CO,1019523,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,158.00,47.40,67.15,134.30,,,,,,,,,,,,,service not payable,,,,,,,79.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,67.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,118.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,79.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,118.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,134.30,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TM MOD 54MM,1019524,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10412.00,3123.60,4039.86,8850.20,,5101.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4373.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4039.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4425.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7809.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5206.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8850.20,,,percent of total billed charges,,,4685.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TM MOD 54MM,1019524,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10412.00,3123.60,4373.04,8850.20,,5101.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4373.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5251.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4425.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7809.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5206.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7809.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8850.20,,,percent of total billed charges,,,4789.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT HEP TW RNG 6MMX70CM,1019527,CDM,0278,RC,L8670,HCPCS,,,,,,inpatient,facility,,,8180.00,2454.00,3173.84,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3173.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6953.0,,,percent of total billed charges,,,3681.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT HEP TW RNG 6MMX70CM,1019527,CDM,0278,RC,L8670,HCPCS,,,,,,outpatient,facility,,,8180.00,2454.00,3435.60,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4125.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6953.0,,,percent of total billed charges,,,3762.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7X40MM X_7182-2340 X_RICHARDS MFG CO,1019529,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,397.00,119.10,154.04,337.45,,,,,,,,,,,,,,,,,,,,154.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,178.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7X40MM X_7182-2340 X_RICHARDS MFG CO,1019529,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,397.00,119.10,168.72,337.45,,,,,,,,,,,,,service not payable,,,,,,,200.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,168.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,297.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,337.45,,,percent of total billed charges,,,182.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 81MM X_71823906 X_RICHARDS MFG CO,1019530,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3715.00,1114.50,1441.42,3157.75,,,,,,,,,,,,,,,,,,,,1441.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3157.75,,,percent of total billed charges,,,1671.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 81MM X_71823906 X_RICHARDS MFG CO,1019530,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3715.00,1114.50,1578.88,3157.75,,,,,,,,,,,,,service not payable,,,,,,,1873.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1578.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3157.75,,,percent of total billed charges,,,1708.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 3.5X10MM X_7182-5010 X_RICHARDS MFG CO,1019531,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,439.00,131.70,170.33,373.15,,,,,,,,,,,,,,,,,,,,170.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,329.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,219.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.15,,,percent of total billed charges,,,197.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 3.5X10MM X_7182-5010 X_RICHARDS MFG CO,1019531,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,439.00,131.70,186.57,373.15,,,,,,,,,,,,,service not payable,,,,,,,221.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,186.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,329.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,219.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,329.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,373.15,,,percent of total billed charges,,,201.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 3.5X14MM X_7182-5014 X_RICHARDS MFG CO,1019532,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,439.00,131.70,170.33,373.15,,,,,,,,,,,,,,,,,,,,170.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,329.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,219.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.15,,,percent of total billed charges,,,197.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 3.5X14MM X_7182-5014 X_RICHARDS MFG CO,1019532,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,439.00,131.70,186.57,373.15,,,,,,,,,,,,,service not payable,,,,,,,221.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,186.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,329.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,219.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,329.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,373.15,,,percent of total billed charges,,,201.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4X30MM,1019533,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4X30MM,1019533,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER SILVER HAWK X_P4024 X_FOX HOLLOW,1019534,CDM,0272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,9615.00,2884.50,4086.38,8172.75,,5942.07,,,percent of total billed charges,,,,,,,,service not payable,4692.12,,,percent of total billed charges,,,4849.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4086.38,,,percent of total billed charges,,,,,,,,,7211.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4807.5,,,percent of total billed charges,,,,,,,,service not payable,7211.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8172.75,,,percent of total billed charges,,,4422.90,,,percent of total billed charges,,,,,,,,,6249.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6249.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIDENT 40MM X_623-00-40F X_STRYKER,1019535,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIDENT 40MM X_623-00-40F X_STRYKER,1019535,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 40MM X_6260-9-140 X_STRYKER,1019536,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5104.00,1531.20,1980.35,4338.40,,2500.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2143.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1980.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2169.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3828.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2552.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4338.40,,,percent of total billed charges,,,2296.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 40MM X_6260-9-140 X_STRYKER,1019536,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5104.00,1531.20,2143.68,4338.40,,2500.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2143.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2574.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2169.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3828.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2552.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3828.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4338.40,,,percent of total billed charges,,,2347.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5MM X_2257-75-65 X_ZIMMER-DAVIS,1019537,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,892.00,267.60,346.10,758.20,,,,,,,,,,,,,,,,,,,,346.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,669.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,446.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.20,,,percent of total billed charges,,,401.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5MM X_2257-75-65 X_ZIMMER-DAVIS,1019537,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,892.00,267.60,379.10,758.20,,,,,,,,,,,,,service not payable,,,,,,,449.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,379.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,669.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,446.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,669.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,758.20,,,percent of total billed charges,,,410.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TWO LEVEL 44MM,1019538,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4493.00,1347.90,1743.28,3819.05,,,,,,,,,,,,,,,,,,,,1743.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1909.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3819.05,,,percent of total billed charges,,,2021.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TWO LEVEL 44MM,1019538,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4493.00,1347.90,1909.52,3819.05,,,,,,,,,,,,,service not payable,,,,,,,2266.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1909.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3819.05,,,percent of total billed charges,,,2066.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE CAPSTONE 14X26MM X_9441426 X_SPINAL GRAFT,1019540,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,17685.00,5305.50,6861.78,15032.25,,8665.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7427.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6861.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7516.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13263.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8842.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15032.25,,,percent of total billed charges,,,7958.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE CAPSTONE 14X26MM X_9441426 X_SPINAL GRAFT,1019540,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,17685.00,5305.50,7427.70,15032.25,,8665.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7427.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8920.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7516.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13263.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8842.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13263.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15032.25,,,percent of total billed charges,,,8135.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4X48MM,1019541,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4X48MM,1019541,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TUBULAR 3.5X107MM X_71829008 X_RICHARDS M,1019542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TUBULAR 3.5X107MM X_71829008 X_RICHARDS M,1019542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE BREAST 650ML X_354-6315 X_MENTOR,1019543,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4254.00,1276.20,1650.55,3615.90,,,,,,,,,,,,,,,,,,,,1650.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1807.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3190.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2127.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.90,,,percent of total billed charges,,,1914.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE BREAST 650ML X_354-6315 X_MENTOR,1019543,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4254.00,1276.20,1807.95,3615.90,,,,,,,,,,,,,service not payable,,,,,,,2145.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1807.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3190.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2127.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3190.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3615.90,,,percent of total billed charges,,,1956.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X55MM X_7182-4055 X_RICHARDS MF,1019547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,101.00,30.30,39.19,85.85,,,,,,,,,,,,,,,,,,,,39.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,75.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.85,,,percent of total billed charges,,,45.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X55MM X_7182-4055 X_RICHARDS MF,1019547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,101.00,30.30,42.92,85.85,,,,,,,,,,,,,service not payable,,,,,,,50.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,75.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,50.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,75.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,85.85,,,percent of total billed charges,,,46.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BREAST X_350-2501BC X_MENTOR,1019551,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4175.00,1252.50,1619.90,3548.75,,,,,,,,,,,,,,,,,,,,1619.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1774.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3131.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2087.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3548.75,,,percent of total billed charges,,,1878.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BREAST X_350-2501BC X_MENTOR,1019551,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4175.00,1252.50,1774.38,3548.75,,,,,,,,,,,,,service not payable,,,,,,,2105.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1774.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3131.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2087.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3131.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3548.75,,,percent of total billed charges,,,1920.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4 HOLE X_19-1045 X_WALTER LORENZE,1019552,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,362.00,108.60,140.46,307.70,,,,,,,,,,,,,,,,,,,,140.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.70,,,percent of total billed charges,,,162.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4 HOLE X_19-1045 X_WALTER LORENZE,1019552,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,362.00,108.60,153.85,307.70,,,,,,,,,,,,,service not payable,,,,,,,182.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,271.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,307.70,,,percent of total billed charges,,,166.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 1.5X4 X_91-6604 X_WALTER LORENZE,1019553,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,256.00,76.80,99.33,217.60,,,,,,,,,,,,,,,,,,,,99.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,192.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.60,,,percent of total billed charges,,,115.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 1.5X4 X_91-6604 X_WALTER LORENZE,1019553,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,256.00,76.80,108.8,217.60,,,,,,,,,,,,,service not payable,,,,,,,129.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,108.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,128.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,192.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,217.60,,,percent of total billed charges,,,117.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUMERAL 11 HOLE X_71822711 X_RICHARDS MFG,1019564,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3664.00,1099.20,1421.63,3114.40,,,,,,,,,,,,,,,,,,,,1421.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2748.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1832.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3114.40,,,percent of total billed charges,,,1648.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUMERAL 11 HOLE X_71822711 X_RICHARDS MFG,1019564,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3664.00,1099.20,1557.2,3114.40,,,,,,,,,,,,,service not payable,,,,,,,1848.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1557.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2748.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1832.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2748.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3114.40,,,percent of total billed charges,,,1685.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT LORDO 8MM X_017708 X_MUSCULAR SKELET,1019566,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5292.00,1587.60,2053.30,4498.20,,2593.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2222.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2053.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2249.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3969.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2646.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4498.20,,,percent of total billed charges,,,2381.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT LORDO 8MM X_017708 X_MUSCULAR SKELET,1019566,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5292.00,1587.60,2222.64,4498.20,,2593.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2222.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2669.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2249.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3969.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2646.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3969.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4498.20,,,percent of total billed charges,,,2434.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RESERVOIR IZ 65ML,1019567,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,7963.00,2388.90,3089.64,6768.55,,3901.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3344.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3089.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3384.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5972.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3981.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6768.55,,,percent of total billed charges,,,3583.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR IZ 65ML,1019567,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,7963.00,2388.90,3344.46,6768.55,,3901.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3344.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4016.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3384.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5972.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3981.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5972.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6768.55,,,percent of total billed charges,,,3662.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIP REAR EXTENDED 2.0CM,1019568,CDM,0278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,8.00,2.40,3.10,6.80,,,,,,,,,,,,,,,,,,,,3.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.80,,,percent of total billed charges,,,3.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIP REAR EXTENDED 2.0CM,1019568,CDM,0278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,8.00,2.40,3.40,6.80,,,,,,,,,,,,,service not payable,,,,,,,4.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.80,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OCCIPITAL X_6900280 X_SOFAMOR DANEK,1019569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7817.00,2345.10,3033.00,6644.45,,3830.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3283.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3033.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3322.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5862.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3908.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6644.45,,,percent of total billed charges,,,3517.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OCCIPITAL X_6900280 X_SOFAMOR DANEK,1019569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7817.00,2345.10,3283.14,6644.45,,3830.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3283.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3942.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3322.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5862.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3908.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5862.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6644.45,,,percent of total billed charges,,,3595.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.0X8MM X_6955408 X_SOFAMOR DANEK,1019570,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2163.00,648.90,839.24,1838.55,,,,,,,,,,,,,,,,,,,,839.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1838.55,,,percent of total billed charges,,,973.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.0X8MM X_6955408 X_SOFAMOR DANEK,1019570,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,,,,,,,,,,,,service not payable,,,,,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.5X6MM X_6955506 X_SOFAMOR DANEK,1019571,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2163.00,648.90,839.24,1838.55,,,,,,,,,,,,,,,,,,,,839.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1838.55,,,percent of total billed charges,,,973.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.5X6MM X_6955506 X_SOFAMOR DANEK,1019571,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,,,,,,,,,,,,service not payable,,,,,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.5X8MM X_6955508 X_SOFAMOR DANEK,1019572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2163.00,648.90,839.24,1838.55,,,,,,,,,,,,,,,,,,,,839.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1838.55,,,percent of total billed charges,,,973.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.5X8MM X_6955508 X_SOFAMOR DANEK,1019572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,,,,,,,,,,,,service not payable,,,,,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BREAST 150ML X_350-1501BC X_MENTOR,1019573,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4175.00,1252.50,1619.90,3548.75,,,,,,,,,,,,,,,,,,,,1619.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1774.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3131.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2087.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3548.75,,,percent of total billed charges,,,1878.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BREAST 150ML X_350-1501BC X_MENTOR,1019573,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4175.00,1252.50,1774.38,3548.75,,,,,,,,,,,,,service not payable,,,,,,,2105.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1774.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3131.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2087.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3131.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3548.75,,,percent of total billed charges,,,1920.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K-WIRE 1.0X150MM X_4411-2000 X_WRIGHT MEDICAL,1019575,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K-WIRE 1.0X150MM X_4411-2000 X_WRIGHT MEDICAL,1019575,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR X_SC-1110-02 X_BOSTON SCIENTIFIC,1019577,CDM,0275,RC,C1820,HCPCS,,,,,,inpatient,facility,,,51411.00,15423.30,19947.47,43699.35,,25191.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21592.62,,,percent of total billed charges,,Paid in addition to inpatient services ,19947.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21849.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38558.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25705.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43699.35,,,percent of total billed charges,,,23134.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR X_SC-1110-02 X_BOSTON SCIENTIFIC,1019577,CDM,0275,RC,C1820,HCPCS,,,,,,outpatient,facility,,,51411.00,15423.30,21592.62,43699.35,,25191.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21592.62,,,percent of total billed charges,,Paid in addition to outpatient services ,25931.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21849.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38558.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25705.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38558.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43699.35,,,percent of total billed charges,,,23649.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE STACKABLE TOP 9MM X_1734-01-309 X_DEPUY,1019587,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3467.00,1040.10,1345.20,2946.95,,,,,,,,,,,,,,,,,,,,1345.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1473.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2600.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1733.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2946.95,,,percent of total billed charges,,,1560.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE STACKABLE TOP 9MM X_1734-01-309 X_DEPUY,1019587,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3467.00,1040.10,1473.47,2946.95,,,,,,,,,,,,,service not payable,,,,,,,1748.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1473.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2600.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1733.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2600.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2946.95,,,percent of total billed charges,,,1594.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT EAR TOTAL X_625 X_GRACE MEDICAL,1019590,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1541.00,462.30,597.91,1309.85,,,,,,,,,,,,,,,,,,,,597.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,654.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.85,,,percent of total billed charges,,,693.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT EAR TOTAL X_625 X_GRACE MEDICAL,1019590,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1541.00,462.30,654.92,1309.85,,,,,,,,,,,,,service not payable,,,,,,,777.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,654.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1309.85,,,percent of total billed charges,,,708.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EAR IMPLANT SHOE X_636-080 X_GRACE MEDICAL,1019591,CDM,0278,RC,L8613,HCPCS,,,,,,inpatient,facility,,,2590.00,777.00,1004.92,2201.5,,,,,,,,,,,,,,,,,,,,1004.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1100.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1942.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2201.5,,,percent of total billed charges,,,1165.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EAR IMPLANT SHOE X_636-080 X_GRACE MEDICAL,1019591,CDM,0278,RC,L8613,HCPCS,,,,,,outpatient,facility,,,2590.00,777.00,1100.75,2201.5,,,,,,,,,,,,,service not payable,,,,,,,1306.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1100.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1942.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1942.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2201.5,,,percent of total billed charges,,,1191.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 7X260MM X_1830-0726S X_ STRYKER ORTHO,10196105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4118.00,1235.40,1597.78,3500.30,,,,,,,,,,,,,,,,,,,,1597.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1750.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3088.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2059.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3500.30,,,percent of total billed charges,,,1853.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 7X260MM X_1830-0726S X_ STRYKER ORTHO,10196105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4118.00,1235.40,1750.15,3500.30,,,,,,,,,,,,,service not payable,,,,,,,2077.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1750.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3088.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2059.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3088.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3500.30,,,percent of total billed charges,,,1894.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 127D SZ3 35MM,10196106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 127D SZ3 35MM,10196106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP CANN 5.0X55MM LG,10196108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2447.00,734.10,949.44,2079.95,,,,,,,,,,,,,,,,,,,,949.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1835.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1223.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2079.95,,,percent of total billed charges,,,1101.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP CANN 5.0X55MM LG,10196108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2447.00,734.10,1039.97,2079.95,,,,,,,,,,,,,service not payable,,,,,,,1234.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1039.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1835.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1223.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1835.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2079.95,,,percent of total billed charges,,,1125.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MESH LONG X_AR-8957-01 X_ARTHREX INC,10196110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8180.00,2454.00,3173.84,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3173.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6953.0,,,percent of total billed charges,,,3681.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MESH LONG X_AR-8957-01 X_ARTHREX INC,10196110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8180.00,2454.00,3435.60,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4125.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6953.0,,,percent of total billed charges,,,3762.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 28X13X124MM 18F,10196111,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,29430.00,8829.00,11418.84,25015.5,,14420.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12360.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11418.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12507.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22072.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14715.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25015.5,,,percent of total billed charges,,,13243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 28X13X124MM 18F,10196111,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,29430.00,8829.00,12360.6,25015.5,,14420.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12360.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14844.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12507.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14715.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22072.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,25015.5,,,percent of total billed charges,,,13537.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONMPONENT INT ILIAC 10MM 7CM,10196112,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10333.00,3099.90,4009.20,8783.05,,5063.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4339.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4009.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4391.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7749.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5166.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8783.05,,,percent of total billed charges,,,4649.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONMPONENT INT ILIAC 10MM 7CM,10196112,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10333.00,3099.90,4339.86,8783.05,,5063.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4339.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5211.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4391.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7749.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5166.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7749.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8783.05,,,percent of total billed charges,,,4753.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROTHESIS EXCLUDER X_CEB231010A X_GORE MEDICAL,10196113,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,37024.00,11107.20,14365.31,31470.40,,18141.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15550.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14365.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15735.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27768.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18512.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31470.40,,,percent of total billed charges,,,16660.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROTHESIS EXCLUDER X_CEB231010A X_GORE MEDICAL,10196113,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,37024.00,11107.20,15550.08,31470.40,,18141.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15550.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18674.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15735.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27768.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18512.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27768.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31470.40,,,percent of total billed charges,,,17031.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT 28X14.5MMX12CM,10196114,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,37886.00,11365.80,14699.77,32203.10,,18564.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15912.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14699.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16101.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28414.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18943.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32203.10,,,percent of total billed charges,,,17048.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT 28X14.5MMX12CM,10196114,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,37886.00,11365.80,15912.12,32203.10,,18564.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15912.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19109.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16101.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28414.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18943.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28414.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32203.10,,,percent of total billed charges,,,17427.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 12F 45CM,10196115,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2872.00,861.60,1220.60,2441.20,,1774.90,,,percent of total billed charges,,,,,,,,service not payable,1401.54,,,percent of total billed charges,,,1448.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1220.60,,,percent of total billed charges,,,,,,,,,2154.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1436.0,,,percent of total billed charges,,,,,,,,service not payable,2154.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2441.20,,,percent of total billed charges,,,1321.12,,,percent of total billed charges,,,,,,,,,1866.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1866.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LP RT 3.5MM SM X_AR-8952MC-SR X_STRYKER ORTH,10196117,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LP RT 3.5MM SM X_AR-8952MC-SR X_STRYKER ORTH,10196117,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SIGMA PS SZ1.5 RT,10198097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SIGMA PS SZ1.5 RT,10198097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ACCUTRAK2 5.5X35MM X_30-0025 X_ACUMED,10198098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ACCUTRAK2 5.5X35MM X_30-0025 X_ACUMED,10198098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PINS SKULL WITH CAP ADULT,10198099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,77.00,23.10,29.88,65.45,,,,,,,,,,,,,,,,,,,,29.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PINS SKULL WITH CAP ADULT,10198099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,77.00,23.10,32.73,65.45,,,,,,,,,,,,,service not payable,,,,,,,38.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,32.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,57.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,38.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,57.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,,35.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 11H POST/LAT RIGHT X_7180-2711 X_SMITH NEPHE,10198168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3956.00,1186.80,1534.93,3362.60,,,,,,,,,,,,,,,,,,,,1534.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1681.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2967.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1978.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3362.60,,,percent of total billed charges,,,1780.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 11H POST/LAT RIGHT X_7180-2711 X_SMITH NEPHE,10198168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3956.00,1186.80,1681.3,3362.60,,,,,,,,,,,,,service not payable,,,,,,,1995.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1681.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2967.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1978.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2967.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3362.60,,,percent of total billed charges,,,1819.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCK 2.7X44MM X_7182-3044 X_SMITH NEPHEW,10198169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,108.00,32.40,41.90,91.80,,,,,,,,,,,,,,,,,,,,41.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,81.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.80,,,percent of total billed charges,,,48.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCK 2.7X44MM X_7182-3044 X_SMITH NEPHEW,10198169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,108.00,32.40,45.90,91.80,,,,,,,,,,,,,service not payable,,,,,,,54.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,45.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,81.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,54.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,81.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,91.80,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 2.5X40MM X_7110-2240S X_SMITH NEPHEW,10198170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1068.00,320.40,414.38,907.80,,,,,,,,,,,,,,,,,,,,414.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,801.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,534.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,907.80,,,percent of total billed charges,,,480.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 2.5X40MM X_7110-2240S X_SMITH NEPHEW,10198170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1068.00,320.40,453.90,907.80,,,,,,,,,,,,,service not payable,,,,,,,538.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,801.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,534.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,801.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,907.80,,,percent of total billed charges,,,491.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE EASYCLIP 12X15-13MM,10198185,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2876.00,862.80,1115.89,2444.60,,,,,,,,,,,,,,,,,,,,1115.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1222.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2157.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1438.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2444.60,,,percent of total billed charges,,,1294.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE EASYCLIP 12X15-13MM,10198185,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2876.00,862.80,1222.3,2444.60,,,,,,,,,,,,,service not payable,,,,,,,1450.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1222.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2157.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1438.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2157.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2444.60,,,percent of total billed charges,,,1322.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Testosterone Adult Male Panel w/SHBG,10198197,CDM,0300,RC,84270,CPT,,,,,,outpatient,facility,,,66.00,19.80,20.64,66.0,,66.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,21.30,,,fee schedule,,,66.0,,,fee schedule,,,45.32,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,44.98,,,fee schedule,,,20.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.73,,,fee schedule,,,49.11,,,fee schedule,,,,,,,,,21.30,,,fee schedule,,,,,,,,,27.81,,,fee schedule,,,44.33,,,fee schedule,,,49.5,,,percent of total billed charges,,,21.30,,,fee schedule,,,20.64,,,fee schedule,,,21.73,,,fee schedule,,,32.70,,,fee schedule,,,21.30,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,21.73,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,23.90,,,fee schedule,,,21.30,,,fee schedule,,,,,,,,,21.08,,,fee schedule,,,21.30,,,fee schedule,,,,,,,,,21.51,,,fee schedule,,,,,,,,
Testosterone Adult Male Panel w/SHBG,10198197,CDM,0300,RC,84270,CPT,400,EAPG,,,,outpatient,facility,,,66.00,19.80,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FEMORAL CMPNT PS SZ3 X_5516-F-301 X_STRYKER ORTHOP,10198363,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL CMPNT PS SZ3 X_5516-F-301 X_STRYKER ORTHOP,10198363,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA VIATRAC X_1008189-19 X_ABBOTT VASCULAR,10198364,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK 1/2 TIBIAL SZ4 5MM X_5545-A-401 X_STRYKER OR,10198365,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3397.00,1019.10,1318.04,2887.45,,,,,,,,,,,,,,,,,,,,1318.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1443.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1698.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2887.45,,,percent of total billed charges,,,1528.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK 1/2 TIBIAL SZ4 5MM X_5545-A-401 X_STRYKER OR,10198365,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3397.00,1019.10,1443.72,2887.45,,,,,,,,,,,,,service not payable,,,,,,,1713.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1443.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2547.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1698.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2887.45,,,percent of total billed charges,,,1562.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FLUTED 16X100MM X_5565-S-016 X_STRYKER ORTHOP,10198366,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3946.00,1183.80,1531.05,3354.10,,,,,,,,,,,,,,,,,,,,1531.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1677.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2959.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1973.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.10,,,percent of total billed charges,,,1775.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FLUTED 16X100MM X_5565-S-016 X_STRYKER ORTHOP,10198366,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3946.00,1183.80,1677.05,3354.10,,,,,,,,,,,,,service not payable,,,,,,,1990.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1677.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2959.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1973.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2959.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3354.10,,,percent of total billed charges,,,1815.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 4.5X38MM X_AR-8545-38 X_ARTHREX INC,10198367,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 4.5X38MM X_AR-8545-38 X_ARTHREX INC,10198367,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 5.5X70MM X_AR-8555-70 X_ARTHREX INC,10198368,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 5.5X70MM X_AR-8555-70 X_ARTHREX INC,10198368,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT SALVATION 7X85MM X_SB017085 X_WRIGHT MEDICAL,10198369,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5905.00,1771.50,2291.14,5019.25,,2893.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2480.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2291.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2509.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2952.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5019.25,,,percent of total billed charges,,,2657.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT SALVATION 7X85MM X_SB017085 X_WRIGHT MEDICAL,10198369,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5905.00,1771.50,2480.10,5019.25,,2893.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2480.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2978.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2509.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4428.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2952.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5019.25,,,percent of total billed charges,,,2716.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT SALVATION 5X160MM X_SB050160 X_WRIGHT MEDICAL,10198370,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5827.00,1748.10,2260.88,4952.95,,2855.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2447.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2260.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2476.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4370.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2913.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4952.95,,,percent of total billed charges,,,2622.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT SALVATION 5X160MM X_SB050160 X_WRIGHT MEDICAL,10198370,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5827.00,1748.10,2447.34,4952.95,,2855.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2447.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2939.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2476.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4370.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2913.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4370.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4952.95,,,percent of total billed charges,,,2680.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT SALVATION 5MM X_SB080050 X_WRIGHT MEDICAL,10198371,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1986.00,595.80,770.57,1688.10,,,,,,,,,,,,,,,,,,,,770.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1489.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,993.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1688.10,,,percent of total billed charges,,,893.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT SALVATION 5MM X_SB080050 X_WRIGHT MEDICAL,10198371,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1986.00,595.80,844.05,1688.10,,,,,,,,,,,,,service not payable,,,,,,,1001.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,844.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1489.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,993.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1489.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1688.10,,,percent of total billed charges,,,913.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 6.5X75MM X_7110-6275S X_SMITH NEPHEW,10198372,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 6.5X75MM X_7110-6275S X_SMITH NEPHEW,10198372,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 6.5X80MM X_7110-6280S X_SMITH NEPHEW,10198373,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 6.5X80MM X_7110-6280S X_SMITH NEPHEW,10198373,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT STD 6.0MMX10CM,10198379,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,1727.00,518.10,670.08,1467.95,,,,,,,,,,,,,,,,,,,,670.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,733.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1295.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,863.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1467.95,,,percent of total billed charges,,,777.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT STD 6.0MMX10CM,10198379,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,1727.00,518.10,733.98,1467.95,,,,,,,,,,,,,service not payable,,,,,,,871.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,733.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1295.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,863.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1295.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1467.95,,,percent of total billed charges,,,794.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Mobile Telemetry Hookup Charge,10200282,CDM,0732,RC,93228,CPT,,,,,,outpatient,facility,,,219.00,65.70,23.41,852.0,,78.91,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,58.88,,,fee schedule,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,109.5,,,fee schedule,,,23.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,109.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,23.41,,,fee schedule,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,23.41,,,fee schedule,,,98.55,,,fee schedule,,,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,852.0,,,per diem,,,,,,,,service not payable,,,,,,,750.0,,,per diem,,,109.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Mobile Telemetry Hookup Charge,10200282,CDM,0732,RC,93228,CPT,2072,EAPG,,,,outpatient,facility,,,219.00,65.70,60.67,145.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,112.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.67,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.67,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.67,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,132.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,145.95,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DRESSING VERAFLO CLENSE CHOICE MD X_ULTVCC05MD X_3,10202400,CDM,0623,RC,A6209,HCPCS,,,,,,outpatient,facility,,,700.00,210.00,297.5,595.0,,432.60,,,percent of total billed charges,,,,,,,,service not payable,341.60,,,percent of total billed charges,,,353.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,297.5,,,percent of total billed charges,,,,,,,,,525.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,350.0,,,percent of total billed charges,,,,,,,,service not payable,525.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,595.0,,,percent of total billed charges,,,322.0,,,percent of total billed charges,,,,,,,,,455.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,455.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER 12X14X20MM X_62-1214-20 X_PIONEER SURG,10202404,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER 12X14X20MM X_62-1214-20 X_PIONEER SURG,10202404,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 12X32X6DEG X_48956126 X_STRYKER,10202405,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 12X32X6DEG X_48956126 X_STRYKER,10202405,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CASE POST LUM 12X26X6DEG X_48955126 X_STRYKER,10202407,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CASE POST LUM 12X26X6DEG X_48955126 X_STRYKER,10202407,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE PIN 3.2MM X_7117-5701 X_SMITH NEPHEW,10202408,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,210.00,63.00,81.48,178.5,,,,,,,,,,,,,,,,,,,,81.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE PIN 3.2MM X_7117-5701 X_SMITH NEPHEW,10202408,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,210.00,63.00,89.25,178.5,,,,,,,,,,,,,service not payable,,,,,,,105.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,89.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,157.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,105.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,157.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,,96.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5X65MM X_7482-0265 X_SMITH NEPHEW,10202409,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1076.00,322.80,417.49,914.60,,,,,,,,,,,,,,,,,,,,417.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,807.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,538.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,914.60,,,percent of total billed charges,,,484.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5X65MM X_7482-0265 X_SMITH NEPHEW,10202409,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1076.00,322.80,457.30,914.60,,,,,,,,,,,,,service not payable,,,,,,,542.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,457.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,807.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,538.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,807.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,914.60,,,percent of total billed charges,,,494.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILATATION 5FR 6X8X130 X_U813068 X_BARD,10202410,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4H 140DEG 100MM X_12-4132 X_SMITH NEPHEW,10202411,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1935.00,580.50,750.78,1644.75,,,,,,,,,,,,,,,,,,,,750.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1451.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,967.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1644.75,,,percent of total billed charges,,,870.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4H 140DEG 100MM X_12-4132 X_SMITH NEPHEW,10202411,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1935.00,580.50,822.38,1644.75,,,,,,,,,,,,,service not payable,,,,,,,976.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,822.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1451.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,967.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1451.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1644.75,,,percent of total billed charges,,,890.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP OCCLUSION YASARGIL 9.0MM,10202414,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2453.00,735.90,951.76,2085.05,,,,,,,,,,,,,,,,,,,,951.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1042.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1839.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1226.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2085.05,,,percent of total billed charges,,,1103.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP OCCLUSION YASARGIL 9.0MM,10202414,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2453.00,735.90,1042.52,2085.05,,,,,,,,,,,,,service not payable,,,,,,,1237.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1042.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1839.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1226.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1839.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2085.05,,,percent of total billed charges,,,1128.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP OCCLUSION YASARGIL 7.0MM,10202415,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2453.00,735.90,951.76,2085.05,,,,,,,,,,,,,,,,,,,,951.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1042.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1839.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1226.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2085.05,,,percent of total billed charges,,,1103.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP OCCLUSION YASARGIL 7.0MM,10202415,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2453.00,735.90,1042.52,2085.05,,,,,,,,,,,,,service not payable,,,,,,,1237.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1042.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1839.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1226.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1839.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2085.05,,,percent of total billed charges,,,1128.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON STERILE 0.7MM X_11583BP X_KARL STORZ,10202417,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1399.00,419.70,594.58,1189.15,,864.58,,,percent of total billed charges,,,,,,,,service not payable,682.71,,,percent of total billed charges,,,705.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,594.58,,,percent of total billed charges,,,,,,,,,1049.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,699.5,,,percent of total billed charges,,,,,,,,service not payable,1049.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1189.15,,,percent of total billed charges,,,643.54,,,percent of total billed charges,,,,,,,,,909.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,909.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER KIT 2 LEADS ESSENTIO,10202418,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,9895.00,2968.50,3839.26,8410.75,,4848.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.90,,,percent of total billed charges,,Paid in addition to inpatient services ,3839.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4205.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7421.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4947.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8410.75,,,percent of total billed charges,,,4452.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER KIT 2 LEADS ESSENTIO,10202418,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,9895.00,2968.50,4155.90,8410.75,,4848.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.90,,,percent of total billed charges,,Paid in addition to outpatient services ,4991.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4205.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7421.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4947.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7421.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8410.75,,,percent of total billed charges,,,4551.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB INOGEN DF4 VR SNGL CHMBR,10202774,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,31805.00,9541.50,12340.34,27034.25,,15584.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13358.1,,,percent of total billed charges,,Paid in addition to inpatient services ,12340.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13517.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23853.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15902.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27034.25,,,percent of total billed charges,,,14312.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB INOGEN DF4 VR SNGL CHMBR,10202774,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,31805.00,9541.50,13358.1,27034.25,,15584.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13358.1,,,percent of total billed charges,,Paid in addition to outpatient services ,16042.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13517.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23853.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15902.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23853.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27034.25,,,percent of total billed charges,,,14630.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CORON DIL TREK 3X6MM X_1012274-06 X_ABBOTT LA,10202775,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 4MMX10CM,10202776,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 4MMX15CM,10202777,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 4MMX20CM,10202778,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 4MMX30CM,10202779,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 4MMX35CM,10202780,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 5MMX12CM X_RBY2C0512 X_PENUMBR,10202781,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 5MMX20CM X_RBY2C0520 X_PENUMBR,10202782,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL RUBY STANDARD 5MMX30CM,10202783,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 6MMX20CM,10202784,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 6MMX30CM,10202785,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 7MMX25CM,10202786,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 8MMX25CM,10202787,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 8MMX40CM,10202788,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 9MMX30CM,10202789,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 10MMX35CM,10202790,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 10MMX40CM,10202791,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 10MMX60CM,10202792,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 14MMX60CM,10202793,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 16MMX60CM,10202794,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 18MMX57CM,10202795,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 20MMX60CM,10202796,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 24MMX57CM,10202797,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 28MMX60CM,10202798,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 32MMX60CM,10202799,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 3MMX15CM,10202800,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SOFT 4MMX15CM,10202801,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SOFT 6MMX20CM,10202802,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SOFT 6MMX30CM,10202803,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 8MMX35CM,10202804,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 8MMX60CM,10202805,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SFT 16MMX50CM,10202806,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL CPLX SOFT 20MMX60CM,10202807,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD 4MMX30CM,10202808,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2368.95,4737.90,,3444.73,,,percent of total billed charges,,,,,,,,service not payable,2720.11,,,percent of total billed charges,,,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Pertussis and Parapertussis PCR,10202812,CDM,0300,RC,87801,CPT,,,,,,outpatient,facility,,,382.00,114.60,66.69,324.70,,298.27,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,68.80,,,fee schedule,,,222.56,,,fee schedule,,,146.40,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,145.31,,,fee schedule,,,66.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",70.18,,,fee schedule,,,158.65,,,fee schedule,,,,,,,,,68.80,,,fee schedule,,,,,,,,,90.16,,,fee schedule,,,143.21,,,fee schedule,,,286.5,,,percent of total billed charges,,,68.80,,,fee schedule,,,66.69,,,fee schedule,,,70.18,,,fee schedule,,,106.03,,,fee schedule,,,68.80,,,fee schedule,,,286.5,,,percent of total billed charges,,,,,,,,,70.18,,,fee schedule,,,,,,,,,324.70,,,percent of total billed charges,,,175.72,,,percent of total billed charges,,,,,,,,,77.22,,,fee schedule,,,68.80,,,fee schedule,,,,,,,,,68.09,,,fee schedule,,,68.80,,,fee schedule,,,,,,,,,69.48,,,fee schedule,,,,,,,,
Pertussis and Parapertussis PCR,10202812,CDM,0300,RC,87801,CPT,397,EAPG,,,,outpatient,facility,,,382.00,114.60,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Closed Tx  Supracondylar or Transcondylar femoral,10204211,CDM,0450,RC,27503,CPT,,,,,,outpatient,facility,,,2901.00,870.30,774.0,2465.85,,1792.82,,,percent of total billed charges,,,,,,,,,1415.69,,,percent of total billed charges,,,1463.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2175.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2175.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2465.85,,,percent of total billed charges,,,1334.46,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Closed Tx  Supracondylar or Transcondylar femoral,10204211,CDM,0450,RC,27503,CPT,05112,APC,,,,outpatient,facility,,,2901.00,870.30,736.05,3524.92,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3228.58,,,fee schedule,,,736.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1565.43,,,fee schedule,,,3524.92,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3181.79,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,736.05,,,fee schedule,,,1565.43,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,736.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1565.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,1550.03,,,fee schedule,,,,,,,,
Closed Tx  Supracondylar or Transcondylar femoral,10204211,CDM,0450,RC,27503,CPT,41,EAPG,,,,outpatient,facility,,,2901.00,870.30,669.25,4928.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4928.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4189.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,669.25,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1856.90,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2042.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW LK COMP HEX 25X4.75MM,10204346,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK COMP HEX 25X4.75MM,10204346,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD 5MMX30CM,10204347,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2368.95,4737.90,,3444.73,,,percent of total billed charges,,,,,,,,service not payable,2720.11,,,percent of total billed charges,,,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD 6MMX30CM,10204348,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2368.95,4737.90,,3444.73,,,percent of total billed charges,,,,,,,,service not payable,2720.11,,,percent of total billed charges,,,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD 8MMX60CM,10204349,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2368.95,4737.90,,3444.73,,,percent of total billed charges,,,,,,,,service not payable,2720.11,,,percent of total billed charges,,,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD J 15CM,10204350,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD J 30CM,10204351,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD J 45CM,10204352,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL RUBY POD J 8MMX60CM,10204353,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN STR 115CM,10204354,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN 115CM 45D,10204355,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN 115CM 90 TIP X_PXSLIMLAN115T90 X,10204356,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN STR 135CM,10204357,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN 135CM 45D,10204358,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN 135CM 90 TIP,10204359,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN STR 150CM X_PXSLIMLAN150STR X_PE,10204360,CDM,0270,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN 150CM 45 TIP,10204361,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICROCATH LANTERN 150CM 90D,10204362,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LP LT 3.5MM MD,10204365,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LP LT 3.5MM MD,10204365,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Liver Fibrosis Chronic Viral Hepatitis,10206217,CDM,0300,RC,81599,CPT,,,,,,outpatient,facility,,,176.00,52.80,74.80,149.60,,108.77,,,percent of total billed charges,,,,,,,,service not payable,86.59,,,fee schedule,,,,,,,,service not payable,88.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,88.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,74.80,,,percent of total billed charges,,,,,,,,,132.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,88.0,,,percent of total billed charges,,,,,,,,service not payable,132.0,,,percent of total billed charges,,,,,,,,service not payable,79.20,,,fee schedule,,,,,,,,,149.60,,,percent of total billed charges,,,80.96,,,percent of total billed charges,,,,,,,,,88.0,,,fee schedule,,,,,,,,service not payable,,,,,,,88.0,,,fee schedule,,,88.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Liver Fibrosis Chronic Viral Hepatitis,10206217,CDM,0300,RC,81599,CPT,385,EAPG,,,,outpatient,facility,,,176.00,52.80,54.96,331.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,281.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,54.96,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,94.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,104.35,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
KIT ANKLE STERILE SUBCHONDROPL,10210097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10032.00,3009.60,3892.42,8527.20,,4915.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4213.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3892.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4263.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7524.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8527.20,,,percent of total billed charges,,,4514.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT ANKLE STERILE SUBCHONDROPL,10210097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10032.00,3009.60,4213.44,8527.20,,4915.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4213.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5060.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4263.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7524.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7524.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8527.20,,,percent of total billed charges,,,4614.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAVICLE 8H RT X_AR-2654CR X_ARTHREX INC,10210098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAVICLE 8H RT X_AR-2654CR X_ARTHREX INC,10210098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX FRAG 2.5X16MM HEXA X_AR-2665-16H X_ARTHR,10210099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1230.00,369.00,477.24,1045.5,,,,,,,,,,,,,,,,,,,,477.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX FRAG 2.5X16MM HEXA X_AR-2665-16H X_ARTHR,10210099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,522.75,1045.5,,,,,,,,,,,,,service not payable,,,,,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,522.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,922.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,922.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF APEX 40MM THD 3X200MM,10210100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,634.00,190.20,245.99,538.90,,,,,,,,,,,,,,,,,,,,245.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,475.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,317.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.90,,,percent of total billed charges,,,285.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF APEX 40MM THD 3X200MM,10210100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,634.00,190.20,269.45,538.90,,,,,,,,,,,,,service not payable,,,,,,,319.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,269.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,475.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,317.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,475.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,538.90,,,percent of total billed charges,,,291.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISTRACTOR ELBOW JOINT EXT DJD,10210101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10124.00,3037.20,3928.11,8605.40,,4960.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4252.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3928.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4302.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7593.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5062.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8605.40,,,percent of total billed charges,,,4555.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISTRACTOR ELBOW JOINT EXT DJD,10210101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10124.00,3037.20,4252.08,8605.40,,4960.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4252.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5106.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4302.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7593.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5062.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7593.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8605.40,,,percent of total billed charges,,,4657.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP PIN HOFFMAN 3 5-11MM X_4922-1-015 X_STRYKER,10210102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2986.00,895.80,1158.57,2538.10,,,,,,,,,,,,,,,,,,,,1158.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1269.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2239.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1493.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2538.10,,,percent of total billed charges,,,1343.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP PIN HOFFMAN 3 5-11MM X_4922-1-015 X_STRYKER,10210102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2986.00,895.80,1269.05,2538.10,,,,,,,,,,,,,service not payable,,,,,,,1506.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1269.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2239.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1493.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2239.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2538.10,,,percent of total billed charges,,,1373.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X8MM,10210103,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X8MM,10210103,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X12MM,10210104,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X12MM,10210104,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X15MM,10210105,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X15MM,10210105,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X18MM,10210106,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X18MM,10210106,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X22MM,10210107,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X22MM,10210107,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X26MM,10210108,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X26MM,10210108,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ONYX RES RX 2.0X30MM,10210109,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ONYX RES RX 2.0X30MM,10210109,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN BONE APEX S/D 5X70X250MM X_5018-7-250 X_STRYKE,10210111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,642.00,192.60,249.10,545.70,,,,,,,,,,,,,,,,,,,,249.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,481.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,321.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.70,,,percent of total billed charges,,,288.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN BONE APEX S/D 5X70X250MM X_5018-7-250 X_STRYKE,10210111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,642.00,192.60,272.85,545.70,,,,,,,,,,,,,service not payable,,,,,,,323.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,272.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,481.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,321.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,481.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,,295.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONN HOFFMANN MRI 11X450MM X_4922-8-450 X_STRY,10210112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,642.00,192.60,249.10,545.70,,,,,,,,,,,,,,,,,,,,249.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,481.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,321.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.70,,,percent of total billed charges,,,288.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONN HOFFMANN MRI 11X450MM X_4922-8-450 X_STRY,10210112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,642.00,192.60,272.85,545.70,,,,,,,,,,,,,service not payable,,,,,,,323.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,272.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,481.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,321.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,481.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,,295.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONN HOFFMANN MRI 11X150MM X_4922-8-150 X_STRY,10210113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1401.00,420.30,543.59,1190.85,,,,,,,,,,,,,,,,,,,,543.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,595.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1050.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,700.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1190.85,,,percent of total billed charges,,,630.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONN HOFFMANN MRI 11X150MM X_4922-8-150 X_STRY,10210113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1401.00,420.30,595.42,1190.85,,,,,,,,,,,,,service not payable,,,,,,,706.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,595.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1050.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,700.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1050.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1190.85,,,percent of total billed charges,,,644.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONN HOFFMANN SEMI CIRC X_4922-7-220 X_STRYKER,10210116,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1875.00,562.50,727.5,1593.75,,,,,,,,,,,,,,,,,,,,727.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1406.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,937.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1593.75,,,percent of total billed charges,,,843.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONN HOFFMANN SEMI CIRC X_4922-7-220 X_STRYKER,10210116,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1875.00,562.50,796.88,1593.75,,,,,,,,,,,,,service not payable,,,,,,,945.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,796.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1406.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,937.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1406.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1593.75,,,percent of total billed charges,,,862.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L-SHAPE 8H RT MICRO 1MM X_25-334-08-09 X_KLS,10210122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,308.00,92.40,119.50,261.80,,,,,,,,,,,,,,,,,,,,119.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,231.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.80,,,percent of total billed charges,,,138.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L-SHAPE 8H RT MICRO 1MM X_25-334-08-09 X_KLS,10210122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,308.00,92.40,130.90,261.80,,,,,,,,,,,,,service not payable,,,,,,,155.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,154.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,231.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,261.80,,,percent of total billed charges,,,141.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT WRIST/FOREARM LT LRG,10210123,CDM,0274,RC,L3980,HCPCS,,,,,,inpatient,facility,,,43.00,12.90,16.68,36.55,,,,,,,,,,,,,,,,,,,,16.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.55,,,percent of total billed charges,,,19.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST/FOREARM LT LRG,10210123,CDM,0274,RC,L3980,HCPCS,,,,,,outpatient,facility,,,43.00,12.90,18.27,97.18,,,,,,,,42.31,,,fee schedule,,,,,,,,,21.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,89.01,,,fee schedule,,,43.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",43.16,,,fee schedule,,,97.18,,,fee schedule,,,,,,,,,42.31,,,fee schedule,,,,,,,,,18.27,,,percent of total billed charges,,Paid in addition to outpatient services ,87.72,,,fee schedule,,,32.25,,,percent of total billed charges,,,42.31,,,fee schedule,,,43.0,,,fee schedule,,,43.16,,,fee schedule,,,21.5,,,percent of total billed charges,,Paid in addition to outpatient services ,42.31,,,fee schedule,,,32.25,,,percent of total billed charges,,,43.0,,,fee schedule,,,43.16,,,fee schedule,,,,,,,,,36.55,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,42.31,,,fee schedule,,,,,,,,,,,,,,,42.31,,,fee schedule,,,,,,,,,42.31,,,fee schedule,,,,,,,,
NAIL TFNA 11X170MM 130D X_04.037.142S X_DEPUY SYNT,10210124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6281.00,1884.30,2437.03,5338.85,,3077.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2638.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2437.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2669.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4710.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3140.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5338.85,,,percent of total billed charges,,,2826.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFNA 11X170MM 130D X_04.037.142S X_DEPUY SYNT,10210124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6281.00,1884.30,2638.02,5338.85,,3077.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2638.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3168.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2669.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4710.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3140.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4710.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5338.85,,,percent of total billed charges,,,2889.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NAIL FEM 10.5X90MM,10210125,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3816.00,1144.80,1480.61,3243.60,,,,,,,,,,,,,,,,,,,,1480.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1621.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2862.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1908.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3243.60,,,percent of total billed charges,,,1717.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NAIL FEM 10.5X90MM,10210125,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3816.00,1144.80,1621.8,3243.60,,,,,,,,,,,,,service not payable,,,,,,,1924.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1621.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2862.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1908.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2862.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3243.60,,,percent of total billed charges,,,1755.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.7X24MM X_53-27224E X_STRYKER ORTHOPAE,10210126,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,403.00,120.90,156.36,342.55,,,,,,,,,,,,,,,,,,,,156.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,302.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.55,,,percent of total billed charges,,,181.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.7X24MM X_53-27224E X_STRYKER ORTHOPAE,10210126,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,403.00,120.90,171.28,342.55,,,,,,,,,,,,,service not payable,,,,,,,203.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,201.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,302.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,342.55,,,percent of total billed charges,,,185.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHNBX 8MMX39MMX135CM,10210127,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHNBX 8MMX39MMX135CM,10210127,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ1-2 9MM X_71453141 X_SMITH NEPH,10212310,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ1-2 9MM X_71453141 X_SMITH NEPH,10212310,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE WRIST VOLAR RT 3H 7 PEG,10212311,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3393.00,1017.90,1316.48,2884.05,,,,,,,,,,,,,,,,,,,,1316.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2884.05,,,percent of total billed charges,,,1526.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE WRIST VOLAR RT 3H 7 PEG,10212311,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3393.00,1017.90,1442.02,2884.05,,,,,,,,,,,,,service not payable,,,,,,,1711.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2884.05,,,percent of total billed charges,,,1560.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL ST FT 2.7X48MM,10212313,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL ST FT 2.7X48MM,10212313,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL ST FT 2.7X42MM,10212314,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL ST FT 2.7X42MM,10212314,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FUSION 10MMX16CM X_71701016R X_SMITH NEPHEW,10212315,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6393.00,1917.90,2480.48,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.05,,,percent of total billed charges,,,2876.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FUSION 10MMX16CM X_71701016R X_SMITH NEPHEW,10212315,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6393.00,1917.90,2685.06,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3224.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.05,,,percent of total billed charges,,,2940.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP 9HL 4.5X177MM X_71829489 X_SMITH NEPHEW,10212316,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1091.00,327.30,423.31,927.35,,,,,,,,,,,,,,,,,,,,423.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,463.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,818.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,545.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.35,,,percent of total billed charges,,,490.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP 9HL 4.5X177MM X_71829489 X_SMITH NEPHEW,10212316,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1091.00,327.30,463.68,927.35,,,,,,,,,,,,,service not payable,,,,,,,550.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,463.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,818.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,545.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,818.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,927.35,,,percent of total billed charges,,,501.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BRD SS NS 10H 4.5X195MM,10212317,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1091.00,327.30,423.31,927.35,,,,,,,,,,,,,,,,,,,,423.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,463.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,818.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,545.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.35,,,percent of total billed charges,,,490.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BRD SS NS 10H 4.5X195MM,10212317,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1091.00,327.30,463.68,927.35,,,,,,,,,,,,,service not payable,,,,,,,550.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,463.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,818.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,545.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,818.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,927.35,,,percent of total billed charges,,,501.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM CERAMIC 28MM 5,10214098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7999.00,2399.70,3103.61,6799.15,,3919.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3359.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3103.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3399.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5999.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3999.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6799.15,,,percent of total billed charges,,,3599.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM CERAMIC 28MM 5,10214098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7999.00,2399.70,3359.58,6799.15,,3919.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3359.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4034.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3399.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5999.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3999.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5999.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6799.15,,,percent of total billed charges,,,3679.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1/3 TUB 9H X_626679 X_STRYKER ORTHOPAEDICS,10214099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2634.00,790.20,1021.99,2238.90,,,,,,,,,,,,,,,,,,,,1021.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1119.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1975.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1317.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2238.90,,,percent of total billed charges,,,1185.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1/3 TUB 9H X_626679 X_STRYKER ORTHOPAEDICS,10214099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2634.00,790.20,1119.45,2238.90,,,,,,,,,,,,,service not payable,,,,,,,1328.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1119.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1975.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1317.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1975.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2238.90,,,percent of total billed charges,,,1211.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LISFRANC LG RT X_AR-8951LR X_ARTHREX INC,10214101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LISFRANC LG RT X_AR-8951LR X_ARTHREX INC,10214101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PARIETAL TEMPORAL,10214103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,28685.00,8605.50,11129.78,24382.25,,14055.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12047.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11129.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12191.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21513.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14342.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24382.25,,,percent of total billed charges,,,12908.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PARIETAL TEMPORAL,10214103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,28685.00,8605.50,12047.70,24382.25,,14055.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12047.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14468.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12191.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21513.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14342.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21513.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24382.25,,,percent of total billed charges,,,13195.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EXT GUIDEZILLA II 8F,10214104,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,1333.64,,,percent of total billed charges,,,,,,,,service not payable,1053.10,,,percent of total billed charges,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIX TORIC 18.0D X_ZCT150U-18.0 X_PRECISION,10214105,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIX TORIC 18.0D X_ZCT150U-18.0 X_PRECISION,10214105,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Destr by Neuro Agent Peripheral/Branch,10214130,CDM,0761,RC,64640,CPT,,,,,,outpatient,facility,,,2202.00,660.60,118.0,1871.7,,1360.84,,,percent of total billed charges,,,,,,,,,1074.58,,,percent of total billed charges,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Destr by Neuro Agent Peripheral/Branch,10214130,CDM,0761,RC,64640,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Destr by Neuro Agent Peripheral/Branch,10214130,CDM,0761,RC,64640,CPT,220,EAPG,,,,outpatient,facility,,,2202.00,660.60,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Destr by Neuro Agent Peripheral/Branch,10214131,CDM,0761,RC,64640,CPT,,,,,,outpatient,facility,,,2202.00,660.60,118.0,1871.7,,1360.84,,,percent of total billed charges,,,,,,,,,1074.58,,,percent of total billed charges,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Destr by Neuro Agent Peripheral/Branch,10214131,CDM,0761,RC,64640,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Destr by Neuro Agent Peripheral/Branch,10214131,CDM,0761,RC,64640,CPT,220,EAPG,,,,outpatient,facility,,,2202.00,660.60,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL SUPRCND 11X300MM X_1826-1130S X_STRYKER ORTHO,10214206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5416.00,1624.80,2101.41,4603.60,,2653.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2274.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2101.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4062.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2708.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4603.60,,,percent of total billed charges,,,2437.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SUPRCND 11X300MM X_1826-1130S X_STRYKER ORTHO,10214206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5416.00,1624.80,2274.72,4603.60,,2653.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2274.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2731.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4062.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2708.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4062.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4603.60,,,percent of total billed charges,,,2491.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB 13X375MM X_1822-1337S X_STRYKER ORTHOPAED,10214207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4085.00,1225.50,1584.98,3472.25,,,,,,,,,,,,,,,,,,,,1584.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1736.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3063.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2042.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3472.25,,,percent of total billed charges,,,1838.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB 13X375MM X_1822-1337S X_STRYKER ORTHOPAED,10214207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4085.00,1225.50,1736.12,3472.25,,,,,,,,,,,,,service not payable,,,,,,,2060.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1736.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3063.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2042.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3063.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3472.25,,,percent of total billed charges,,,1879.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SOL SYS 12-14 STR 8IN,10214208,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,28328.00,8498.40,10991.26,24078.80,,13880.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11897.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10991.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12039.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24078.80,,,percent of total billed charges,,,12747.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SOL SYS 12-14 STR 8IN,10214208,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,28328.00,8498.40,11897.76,24078.80,,13880.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11897.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14288.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12039.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24078.80,,,percent of total billed charges,,,13030.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CERV 4D W/PLG 5MM X_77102054 X_STRYKER S,10216280,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT CERV 4D W/PLG 5MM X_77102054 X_STRYKER S,10216280,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4 LEVEL 68MM X_48811438 X_STRYKER SPINE,10216281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4 LEVEL 68MM X_48811438 X_STRYKER SPINE,10216281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 10X2.3MM PEEK INT X_AR-1400P X_ARTHREX INC,10216283,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 10X2.3MM PEEK INT X_AR-1400P X_ARTHREX INC,10216283,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LC-DCP 9H STR 3.5X116MM,10216284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,992.00,297.60,384.90,843.20,,,,,,,,,,,,,,,,,,,,384.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,744.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,496.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,843.20,,,percent of total billed charges,,,446.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LC-DCP 9H STR 3.5X116MM,10216284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,992.00,297.60,421.60,843.20,,,,,,,,,,,,,service not payable,,,,,,,500.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,421.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,744.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,496.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,744.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,843.20,,,percent of total billed charges,,,456.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE SIGMA PFC DIS LT SZ4 8MM,10216285,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE SIGMA PFC DIS LT SZ4 8MM,10216285,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA SZ4 17.5MM,10216287,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA SZ4 17.5MM,10216287,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LORENZ STR 2H MD 1.5MM,10216289,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LORENZ STR 2H MD 1.5MM,10216289,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ECLIPSE COLLARLESS HIGH SZ 11,10216290,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ECLIPSE COLLARLESS HIGH SZ 11,10216290,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.0X46MM LONG X_AR-8840PL-46 X_ARTHREX INC,10216292,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.0X46MM LONG X_AR-8840PL-46 X_ARTHREX INC,10216292,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH ENTRADA 11CM 4.5IN,10216293,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,66.00,19.80,28.05,56.10,,40.79,,,percent of total billed charges,,,,,,,,service not payable,32.21,,,percent of total billed charges,,,33.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,42.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,42.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE INOGEN DF4 1 LEAD X_8F4A X_BOSTON SCIENTIFI,10216294,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,29985.00,8995.50,11634.18,25487.25,,14692.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12593.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11634.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12743.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22488.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14992.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25487.25,,,percent of total billed charges,,,13493.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE INOGEN DF4 1 LEAD X_8F4A X_BOSTON SCIENTIFI,10216294,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,29985.00,8995.50,12593.70,25487.25,,14692.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12593.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15124.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12743.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22488.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14992.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22488.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,25487.25,,,percent of total billed charges,,,13793.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VEIN SAPHENOUS CRYO 80CMX>3MM,10216295,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,23055.00,6916.50,8945.34,19596.75,,11296.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9683.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8945.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9798.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17291.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11527.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19596.75,,,percent of total billed charges,,,10374.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VEIN SAPHENOUS CRYO 80CMX>3MM,10216295,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,23055.00,6916.50,9683.10,19596.75,,11296.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9683.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11628.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9798.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17291.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11527.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17291.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19596.75,,,percent of total billed charges,,,10605.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 4X40MM NONSTERIL,10216297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,773.00,231.90,299.92,657.05,,,,,,,,,,,,,,,,,,,,299.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,579.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.05,,,percent of total billed charges,,,347.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 4X40MM NONSTERIL,10216297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,773.00,231.90,328.52,657.05,,,,,,,,,,,,,service not payable,,,,,,,389.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,579.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,386.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,579.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.05,,,percent of total billed charges,,,355.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 6FR 0.038INX22CM,10216303,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 6FR 0.038INX22CM,10216303,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 6FR 0.038INX24CM,10216304,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 6FR 0.038INX24CM,10216304,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 6FR 0.038INX26CM,10216305,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 6FR 0.038INX26CM,10216305,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 6FR 0.038INX28CM,10216306,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 6FR 0.038INX28CM,10216306,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 7FR 0.038INX24CM,10216307,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 7FR 0.038INX24CM,10216307,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 7FR 0.038INX26CM,10216308,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 7FR 0.038INX26CM,10216308,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT MARDIS 7FR 0.038INX28CM,10216309,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,848.00,254.40,329.02,720.80,,,,,,,,,,,,,,,,,,,,329.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.80,,,percent of total billed charges,,,381.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT MARDIS 7FR 0.038INX28CM,10216309,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,848.00,254.40,360.40,720.80,,,,,,,,,,,,,service not payable,,,,,,,427.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,360.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,720.80,,,percent of total billed charges,,,390.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERCUFLEX 7FR 80CM OPEN,10216310,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,1030.00,309.00,399.64,875.5,,,,,,,,,,,,,,,,,,,,399.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,772.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,515.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,875.5,,,percent of total billed charges,,,463.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERCUFLEX 7FR 80CM OPEN,10216310,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,1030.00,309.00,437.75,875.5,,,,,,,,,,,,,service not payable,,,,,,,519.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,437.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,772.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,515.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,772.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,875.5,,,percent of total billed charges,,,473.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERCUFLEX 8FR 80CM OPEN,10216311,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,1030.00,309.00,399.64,875.5,,,,,,,,,,,,,,,,,,,,399.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,772.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,515.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,875.5,,,percent of total billed charges,,,463.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERCUFLEX 8FR 80CM OPEN,10216311,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,1030.00,309.00,437.75,875.5,,,,,,,,,,,,,service not payable,,,,,,,519.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,437.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,772.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,515.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,772.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,875.5,,,percent of total billed charges,,,473.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE AMPLATZ PTFE 0.035IN,10216312,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,140.00,42.00,59.5,119.0,,86.52,,,percent of total billed charges,,,,,,,,service not payable,68.32,,,percent of total billed charges,,,70.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,105.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,70.0,,,percent of total billed charges,,,,,,,,service not payable,105.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,,64.40,,,percent of total billed charges,,,,,,,,,91.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,91.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH NAV HD 13F 11X36CM,10216313,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,658.00,197.40,279.65,559.30,,406.64,,,percent of total billed charges,,,,,,,,service not payable,321.10,,,percent of total billed charges,,,331.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.65,,,percent of total billed charges,,,,,,,,,493.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,329.0,,,percent of total billed charges,,,,,,,,service not payable,493.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,559.30,,,percent of total billed charges,,,302.68,,,percent of total billed charges,,,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH NAV HD 12-14F 28CM,10216314,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,658.00,197.40,279.65,559.30,,406.64,,,percent of total billed charges,,,,,,,,service not payable,321.10,,,percent of total billed charges,,,331.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.65,,,percent of total billed charges,,,,,,,,,493.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,329.0,,,percent of total billed charges,,,,,,,,service not payable,493.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,559.30,,,percent of total billed charges,,,302.68,,,percent of total billed charges,,,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH NAV HD 12-14F 36CM,10216315,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,658.00,197.40,279.65,559.30,,406.64,,,percent of total billed charges,,,,,,,,service not payable,321.10,,,percent of total billed charges,,,331.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.65,,,percent of total billed charges,,,,,,,,,493.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,329.0,,,percent of total billed charges,,,,,,,,service not payable,493.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,559.30,,,percent of total billed charges,,,302.68,,,percent of total billed charges,,,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH NAV HD 12-14F 46CM,10216316,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,658.00,197.40,279.65,559.30,,406.64,,,percent of total billed charges,,,,,,,,service not payable,321.10,,,percent of total billed charges,,,331.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.65,,,percent of total billed charges,,,,,,,,,493.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,329.0,,,percent of total billed charges,,,,,,,,service not payable,493.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,559.30,,,percent of total billed charges,,,302.68,,,percent of total billed charges,,,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Pseudocholinesterase,10218,CDM,0300,RC,82480,CPT,,,,,,outpatient,facility,,,66.00,19.80,7.48,56.10,,33.47,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.71,,,fee schedule,,,24.98,,,fee schedule,,,16.41,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,16.29,,,fee schedule,,,7.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.86,,,fee schedule,,,17.79,,,fee schedule,,,,,,,,,7.71,,,fee schedule,,,,,,,,,10.12,,,fee schedule,,,16.05,,,fee schedule,,,49.5,,,percent of total billed charges,,,7.71,,,fee schedule,,,7.48,,,fee schedule,,,7.86,,,fee schedule,,,11.9,,,fee schedule,,,7.71,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,7.86,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,8.66,,,fee schedule,,,7.71,,,fee schedule,,,,,,,,,7.63,,,fee schedule,,,7.71,,,fee schedule,,,,,,,,,7.79,,,fee schedule,,,,,,,,
Pseudocholinesterase,10218,CDM,0300,RC,82480,CPT,402,EAPG,,,,outpatient,facility,,,66.00,19.80,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ALLOGRAFT GRAFTLINK CONV PK IMP SYS X_AR-1588AL-CP,10218098,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4109.00,1232.70,1594.29,3492.65,,,,,,,,,,,,,,,,,,,,1594.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1746.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3081.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2054.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3492.65,,,percent of total billed charges,,,1849.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT GRAFTLINK CONV PK IMP SYS X_AR-1588AL-CP,10218098,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4109.00,1232.70,1746.32,3492.65,,,,,,,,,,,,,service not payable,,,,,,,2072.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1746.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3081.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2054.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3081.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3492.65,,,percent of total billed charges,,,1890.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 0D 7X25MM,10218100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 0D 7X25MM,10218100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 600CC,10218102,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 600CC,10218102,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 750CC,10218103,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 750CC,10218103,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETER ASCERTA 4.8F 30CM,10218104,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETER ASCERTA 4.8F 30CM,10218104,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL CONTOUR 6F 20CM,10218105,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,604.00,181.20,234.35,513.40,,,,,,,,,,,,,,,,,,,,234.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,453.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,302.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.40,,,percent of total billed charges,,,271.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL CONTOUR 6F 20CM,10218105,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,604.00,181.20,256.70,513.40,,,,,,,,,,,,,service not payable,,,,,,,304.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,256.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,453.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,302.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,453.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,513.40,,,percent of total billed charges,,,277.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETER ASCERTA 4.8F 24CM,10218106,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETER ASCERTA 4.8F 24CM,10218106,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 6F 22CM,10218107,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 6F 22CM,10218107,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 6F 24CM,10218108,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 6F 24CM,10218108,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 6F 26CM,10218109,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 6F 26CM,10218109,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 6F 28CM,10218110,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 6F 28CM,10218110,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 6F 30CM,10218111,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 6F 30CM,10218111,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 7F 22CM,10218112,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 7F 22CM,10218112,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 7F 24CM,10218113,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 7F 24CM,10218113,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 7F 26CM,10218114,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 7F 26CM,10218114,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 7F 28CM,10218115,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 7F 28CM,10218115,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL ASCERTA 7F 30CM,10218116,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL ASCERTA 7F 30CM,10218116,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ZIP HP 0.025X150 ANG,10218117,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,200.00,60.00,85.0,170.0,,123.60,,,percent of total billed charges,,,,,,,,service not payable,97.60,,,percent of total billed charges,,,100.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,85.0,,,percent of total billed charges,,,,,,,,,150.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,100.0,,,percent of total billed charges,,,,,,,,service not payable,150.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,170.0,,,percent of total billed charges,,,92.0,,,percent of total billed charges,,,,,,,,,130.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,130.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PERI LOC 4X32MM X_71101032 X_SMITH NEPH,10218125,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PERI LOC 4X32MM X_71101032 X_SMITH NEPH,10218125,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neo PDGFRa Mutation (81314),10218139,CDM,0310,RC,81314,CPT,,,,,,outpatient,facility,,,607.00,182.10,279.22,744.69,,375.13,,,percent of total billed charges,,,322.92,,,fee schedule,,,298.64,,,fee schedule,,,687.20,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,682.09,,,fee schedule,,,313.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",329.38,,,fee schedule,,,744.69,,,fee schedule,,,,,,,,,322.92,,,fee schedule,,,,,,,,,423.80,,,fee schedule,,,672.20,,,fee schedule,,,455.25,,,percent of total billed charges,,,322.92,,,fee schedule,,,313.03,,,fee schedule,,,329.38,,,fee schedule,,,498.42,,,fee schedule,,,322.92,,,fee schedule,,,455.25,,,percent of total billed charges,,,313.03,,,fee schedule,,,329.38,,,fee schedule,,,,,,,,,515.95,,,percent of total billed charges,,,279.22,,,percent of total billed charges,,,,,,,,,362.46,,,fee schedule,,,322.92,,,fee schedule,,,,,,,,,319.62,,,fee schedule,,,322.92,,,fee schedule,,,,,,,,,326.15,,,fee schedule,,,,,,,,
Neo PDGFRa Mutation (81314),10218139,CDM,0310,RC,81314,CPT,386,EAPG,,,,outpatient,facility,,,607.00,182.10,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Neo Androgen Receptor Mutation,10218140,CDM,0310,RC,81204,CPT,,,,,,outpatient,facility,,,404.00,121.20,130.15,343.40,,249.67,,,percent of total billed charges,,,134.26,,,fee schedule,,,198.77,,,fee schedule,,,285.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,283.59,,,fee schedule,,,130.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",136.95,,,fee schedule,,,309.62,,,fee schedule,,,,,,,,,134.26,,,fee schedule,,,,,,,,,176.09,,,fee schedule,,,279.48,,,fee schedule,,,303.0,,,percent of total billed charges,,,134.26,,,fee schedule,,,130.15,,,fee schedule,,,136.95,,,fee schedule,,,207.09,,,fee schedule,,,134.26,,,fee schedule,,,303.0,,,percent of total billed charges,,,130.15,,,fee schedule,,,136.95,,,fee schedule,,,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,150.70,,,fee schedule,,,134.26,,,fee schedule,,,,,,,,,132.89,,,fee schedule,,,134.26,,,fee schedule,,,,,,,,,135.60,,,fee schedule,,,,,,,,
Neo Androgen Receptor Mutation,10218140,CDM,0310,RC,81204,CPT,386,EAPG,,,,outpatient,facility,,,404.00,121.20,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH MINI TREK 1.2X8MM X_1012268-08U X_ABBOTT LABO,10220107,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LO-PRO PT 6X45MM X_AR-9060-45PT X_ARTHREX IN,10220108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LO-PRO PT 6X45MM X_AR-9060-45PT X_ARTHREX IN,10220108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 16X83MM,10220109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 16X83MM,10220109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE SERRATO 6.5X50MM,10220110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE SERRATO 6.5X50MM,10220110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEXALOBE 3.5X34MM,10222155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEXALOBE 3.5X34MM,10222155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 8X15 X_VBJR081502A X_W L GORE,10222157,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,13408.00,4022.40,5202.30,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5202.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11396.80,,,percent of total billed charges,,,6033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 8X15 X_VBJR081502A X_W L GORE,10222157,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,13408.00,4022.40,5631.36,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6763.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11396.80,,,percent of total billed charges,,,6167.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUTOGRAFT GRAFTLINK X_AR-1588AU-CP X_ARTHREX INC,10222158,CDM,0278,RC,C9362,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUTOGRAFT GRAFTLINK X_AR-1588AU-CP X_ARTHREX INC,10222158,CDM,0278,RC,C9362,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUTOGRAFT GRAFTLINK X_AR-1588AU-CP X_ARTHREX INC,10222158,CDM,0278,RC,C9362,HCPCS,455,EAPG,,,,outpatient,facility,,,2973.00,891.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROLAYER 4X8CM 1.0 2.0MM THICK,10226098,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,9644.00,2893.20,3741.87,8197.40,,4725.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4050.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3741.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4098.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7233.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4822.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8197.40,,,percent of total billed charges,,,4339.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROLAYER 4X8CM 1.0 2.0MM THICK,10226098,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,9644.00,2893.20,4050.48,8197.40,,4725.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4050.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4864.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4098.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7233.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4822.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7233.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8197.40,,,percent of total billed charges,,,4436.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROX AAA ZE 14X11X90MM,10226101,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10730.00,3219.00,4163.24,9120.5,,5257.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4506.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4163.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4560.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8047.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5365.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9120.5,,,percent of total billed charges,,,4828.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROX AAA ZE 14X11X90MM,10226101,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10730.00,3219.00,4506.60,9120.5,,5257.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4506.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5412.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4560.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8047.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5365.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8047.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9120.5,,,percent of total billed charges,,,4935.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ENDOVASC 2X30X124 X_ZFEN-P-2-30-124-R X_COOK,10226103,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24041.00,7212.30,9327.91,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9327.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20434.85,,,percent of total billed charges,,,10818.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ENDOVASC 2X30X124 X_ZFEN-P-2-30-124-R X_COOK,10226103,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24041.00,7212.30,10097.22,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12126.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20434.85,,,percent of total billed charges,,,11058.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 8X20X130,10226105,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIBERLINK-0 BLUE X_AR-7258 X_ARTHREX INC,10226183,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIBERLINK-0 BLUE X_AR-7258 X_ARTHREX INC,10226183,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIGERLINK-O WHITE/BLACK X_AR-7258T X_ARTHREX INC,10226184,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIGERLINK-O WHITE/BLACK X_AR-7258T X_ARTHREX INC,10226184,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS IMPLANT SCND FIX W/SWIVELOCK 4.75X19.1 X_AR-15,10226185,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS IMPLANT SCND FIX W/SWIVELOCK 4.75X19.1 X_AR-15,10226185,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST CORT 4.5X26MM X_340626 X_340510 X_STRYKER,10226186,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,148.00,44.40,57.42,125.8,,,,,,,,,,,,,,,,,,,,57.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,66.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST CORT 4.5X26MM X_340626 X_340510 X_STRYKER,10226186,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,,,,,,,,,,,,service not payable,,,,,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5X26MM X_371326 X_STRYKER,10226187,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,694.00,208.20,269.27,589.90,,,,,,,,,,,,,,,,,,,,269.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,520.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,347.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,589.90,,,percent of total billed charges,,,312.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5X26MM X_371326 X_STRYKER,10226187,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,694.00,208.20,294.95,589.90,,,,,,,,,,,,,service not payable,,,,,,,350.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,294.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,520.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,347.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,520.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,589.90,,,percent of total billed charges,,,319.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DYNANITE 9X10MM,10226188,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYNANITE 9X10MM,10226188,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ACETABULAR 36X58MM,10226189,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ACETABULAR 36X58MM,10226189,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LUGS FEMORAL GII X_71420999 X_SMITH NEPHEW,10226190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,268.00,80.40,103.98,227.80,,,,,,,,,,,,,,,,,,,,103.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,,120.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LUGS FEMORAL GII X_71420999 X_SMITH NEPHEW,10226190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,268.00,80.40,113.90,227.80,,,,,,,,,,,,,service not payable,,,,,,,135.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,113.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,201.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,134.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,201.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SINUS PROPEL CONTOUR X_50011 X_INTERSECT E,10226194,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3525.00,1057.50,1367.7,2996.25,,,,,,,,,,,,,,,,,,,,1367.7,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1498.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2996.25,,,percent of total billed charges,,,1586.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SINUS PROPEL CONTOUR X_50011 X_INTERSECT E,10226194,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3525.00,1057.50,1498.12,2996.25,,,,,,,,,,,,,service not payable,,,,,,,1778.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1498.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2996.25,,,percent of total billed charges,,,1621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT T8 2.7X28MM X_656328 X_STRYKER ORTHO,10228098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT T8 2.7X28MM X_656328 X_STRYKER ORTHO,10228098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U4 3.5X10X150,10228099,CDM,0272,RC,C1882,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS INOGEN DEFIB 2LEAD DF4 X_8F62 X_BOSTON SCIENTI,10228101,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,31805.00,9541.50,12340.34,27034.25,,15584.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13358.1,,,percent of total billed charges,,Paid in addition to inpatient services ,12340.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13517.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23853.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15902.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27034.25,,,percent of total billed charges,,,14312.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS INOGEN DEFIB 2LEAD DF4 X_8F62 X_BOSTON SCIENTI,10228101,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,31805.00,9541.50,13358.1,27034.25,,15584.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13358.1,,,percent of total billed charges,,Paid in addition to outpatient services ,16042.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13517.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23853.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15902.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23853.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27034.25,,,percent of total billed charges,,,14630.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LCKG 2.7X19MM X_25-774-19-91 X_KLS MART,10230097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,630.00,189.00,244.44,535.5,,,,,,,,,,,,,,,,,,,,244.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,315.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,,283.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LCKG 2.7X19MM X_25-774-19-91 X_KLS MART,10230097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,630.00,189.00,267.75,535.5,,,,,,,,,,,,,service not payable,,,,,,,317.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,472.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,315.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,472.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,535.5,,,percent of total billed charges,,,289.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LIFESTENT 5F 135CM 6X150MM,10230101,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3782.00,1134.60,1467.42,3214.70,,,,,,,,,,,,,,,,,,,,1467.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1607.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3214.70,,,percent of total billed charges,,,1701.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIFESTENT 5F 135CM 6X150MM,10230101,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3782.00,1134.60,1607.35,3214.70,,,,,,,,,,,,,service not payable,,,,,,,1907.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1607.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3214.70,,,percent of total billed charges,,,1739.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE ANCHOR NANO CORKSCREW FT TI W 3-0 FW X_AR-1,10230158,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE ANCHOR NANO CORKSCREW FT TI W 3-0 FW X_AR-1,10230158,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Frenotomy,10230180,CDM,0490,RC,41010,CPT,,,,,,outpatient,facility,,,1968.00,590.40,905.28,3044.0,,1968.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,992.66,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1672.8,,,percent of total billed charges,,,905.28,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Frenotomy,10230180,CDM,0490,RC,41010,CPT,05163,APC,,,,outpatient,facility,,,1968.00,590.40,1362.52,3262.54,,,,,,,,1420.5,,,fee schedule,,,,,,,,,,,,,,,2988.25,,,fee schedule,,,1362.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1448.91,,,fee schedule,,,3262.54,,,fee schedule,,,,,,,,,1420.5,,,fee schedule,,,,,,,,,,,,,,,2944.94,,,fee schedule,,,,,,,,,1420.5,,,fee schedule,,,1362.52,,,fee schedule,,,1448.91,,,fee schedule,,,,,,,,,1420.5,,,fee schedule,,,,,,,,,1362.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1448.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1420.5,,,fee schedule,,,,,,,,,,,,,,,1420.5,,,fee schedule,,,,,,,,,1434.65,,,fee schedule,,,,,,,,
Frenotomy,10230180,CDM,0490,RC,41010,CPT,252,EAPG,,,,outpatient,facility,,,1968.00,590.40,1968.0,5223.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5223.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4440.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1968.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1968.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1968.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2365.30,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2601.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
AUGMENT GLENOID CORTILOC MED RT X_DWK404RA25S X_TO,10230190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12248.00,3674.40,4752.22,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4752.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10410.80,,,percent of total billed charges,,,5511.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT GLENOID CORTILOC MED RT X_DWK404RA25S X_TO,10230190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12248.00,3674.40,5144.16,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6177.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10410.80,,,percent of total billed charges,,,5634.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 56X21MM X_7122891 X_TORNIER INC,10230192,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11782.00,3534.60,4571.42,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4571.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10014.70,,,percent of total billed charges,,,5301.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 56X21MM X_7122891 X_TORNIER INC,10230192,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11782.00,3534.60,4948.44,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5942.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10014.70,,,percent of total billed charges,,,5419.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7.0X65MM,10230194,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7.0X65MM,10230194,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL FOOT 3MM MED X_AR-8952DFW X_ARTHREX I,10230195,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7939.00,2381.70,3080.33,6748.15,,3890.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3334.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3080.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3374.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5954.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3969.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6748.15,,,percent of total billed charges,,,3572.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL FOOT 3MM MED X_AR-8952DFW X_ARTHREX I,10230195,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7939.00,2381.70,3334.38,6748.15,,3890.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3334.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4004.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3374.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5954.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3969.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5954.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6748.15,,,percent of total billed charges,,,3651.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX34CM LT X_71649734 X_SMITH NEPHEW,10230196,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10278.00,3083.40,3987.86,8736.30,,5036.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4316.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3987.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4368.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7708.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5139.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8736.30,,,percent of total billed charges,,,4625.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX34CM LT X_71649734 X_SMITH NEPHEW,10230196,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10278.00,3083.40,4316.76,8736.30,,5036.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4316.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5184.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4368.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7708.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5139.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7708.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8736.30,,,percent of total billed charges,,,4727.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW KIT COMP 80X75MM,10230198,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW KIT COMP 80X75MM,10230198,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL MOD PLUS 255CC,10230200,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL MOD PLUS 255CC,10230200,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL MOD PLUS 295CC,10230201,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL MOD PLUS 295CC,10230201,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST GEL MOD PLUS 375ML X_334-1255 X_MENTO,10230202,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST GEL MOD PLUS 375ML X_334-1255 X_MENTO,10230202,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST GEL HP 300ML X_334-1102 X_MENTOR,10230203,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST GEL HP 300ML X_334-1102 X_MENTOR,10230203,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON EXPANDABLE 12X38 80CM,10232209,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON EXPANDABLE 12X38 80CM,10232209,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST CPG GEL HP 330ML,10232213,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST CPG GEL HP 330ML,10232213,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL 6F 22-30CM,10232215,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL 6F 22-30CM,10232215,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 5.0X44MM X_AR-8540-44H X_ARTHREX INC,10232327,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 5.0X44MM X_AR-8540-44H X_ARTHREX INC,10232327,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH JB1 BRAIDED 5F 65CM X_M001314210 X_BOSTON SCI,10232328,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT OTW SUP 80X4.5MM BL X_S-45-080-120-P6 X_ABBO,10232358,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4770.00,1431.00,1850.76,4054.5,,,,,,,,,,,,,,,,,,,,1850.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4054.5,,,percent of total billed charges,,,2146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT OTW SUP 80X4.5MM BL X_S-45-080-120-P6 X_ABBO,10232358,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4770.00,1431.00,2027.25,4054.5,,,,,,,,,,,,,service not payable,,,,,,,2405.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4054.5,,,percent of total billed charges,,,2194.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 26MM X_48811226 X_STRYKER,10232360,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 26MM X_48811226 X_STRYKER,10232360,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE XIAIII TI RAD 50X6MM,10232361,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE XIAIII TI RAD 50X6MM,10232361,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 6IN ECHO 2,10232362,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 6IN ECHO 2,10232362,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER CRTD X_DTMA1D4 X_MEDTRONIC,10232364,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,36475.00,10942.50,14152.30,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,14152.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31003.75,,,percent of total billed charges,,,16413.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER CRTD X_DTMA1D4 X_MEDTRONIC,10232364,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,36475.00,10942.50,15319.5,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,18397.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31003.75,,,percent of total billed charges,,,16778.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLESS 3X24MM,10232659,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2313.00,693.90,897.44,1966.05,,,,,,,,,,,,,,,,,,,,897.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1734.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1156.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1966.05,,,percent of total billed charges,,,1040.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLESS 3X24MM,10232659,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2313.00,693.90,983.02,1966.05,,,,,,,,,,,,,service not payable,,,,,,,1166.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,983.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1734.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1156.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1734.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1966.05,,,percent of total billed charges,,,1063.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LP LT 3.5MM MD X_AR-8952MC-LL X_ARTHREX INC,10232660,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LP LT 3.5MM MD X_AR-8952MC-LL X_ARTHREX INC,10232660,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT 10MM ALLOCRAFT X_44015010 X_STRYKER SPIN,10232662,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT 10MM ALLOCRAFT X_44015010 X_STRYKER SPIN,10232662,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK LP TI 3X24MM TI X_AR-6933V-20 X_ARTHREX I,10232665,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK LP TI 3X24MM TI X_AR-6933V-20 X_ARTHREX I,10232665,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DORSAL MIDFOOT MD 3MM,10232666,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DORSAL MIDFOOT MD 3MM,10232666,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC CERVICAL MOBI-X 15X17MM,10234096,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC CERVICAL MOBI-X 15X17MM,10234096,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC CERV MOBI-C H6 15X15MM,10234098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC CERV MOBI-C H6 15X15MM,10234098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4X2H X_57-05192 X_STRYKER ORTHOPAEDICS,10234100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1766.00,529.80,685.21,1501.10,,,,,,,,,,,,,,,,,,,,685.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,750.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,883.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1501.10,,,percent of total billed charges,,,794.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4X2H X_57-05192 X_STRYKER ORTHOPAEDICS,10234100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1766.00,529.80,750.55,1501.10,,,,,,,,,,,,,service not payable,,,,,,,890.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,750.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1324.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,883.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1324.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1501.10,,,percent of total billed charges,,,812.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS TORIC 18.5 X_ZCT150-18.5 X_PRECISION L,10234103,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC 18.5 X_ZCT150-18.5 X_PRECISION L,10234103,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W/SUPPORT 8 X_MXPRS08 X_COOPER SURGIC,10234106,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,222.00,66.60,86.14,188.70,,,,,,,,,,,,,,,,,,,,86.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.70,,,percent of total billed charges,,,99.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W/SUPPORT 8 X_MXPRS08 X_COOPER SURGIC,10234106,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,222.00,66.60,94.35,188.70,,,,,,,,,,,,,service not payable,,,,,,,111.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,166.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,188.70,,,percent of total billed charges,,,102.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W/SUPPORT 9 X_MXPRS09 X_COOPER SURGIC,10234107,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,222.00,66.60,86.14,188.70,,,,,,,,,,,,,,,,,,,,86.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.70,,,percent of total billed charges,,,99.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W/SUPPORT 9 X_MXPRS09 X_COOPER SURGIC,10234107,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,222.00,66.60,94.35,188.70,,,,,,,,,,,,,service not payable,,,,,,,111.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,166.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,166.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,188.70,,,percent of total billed charges,,,102.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LISFRANC TI MD RT,10234192,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LISFRANC TI MD RT,10234192,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CHS AMBI 8SL X_121146 X_SMITH NEPHEW,10234193,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2530.00,759.00,981.64,2150.5,,,,,,,,,,,,,,,,,,,,981.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1075.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1897.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1265.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2150.5,,,percent of total billed charges,,,1138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CHS AMBI 8SL X_121146 X_SMITH NEPHEW,10234193,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2530.00,759.00,1075.25,2150.5,,,,,,,,,,,,,service not payable,,,,,,,1276.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1075.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1897.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1265.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1897.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2150.5,,,percent of total billed charges,,,1163.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OLEC LT ULNA 3H 65MM X_629343 X_STRYKER ORTH,10236122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3462.00,1038.60,1343.26,2942.70,,,,,,,,,,,,,,,,,,,,1343.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1471.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2596.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1731.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2942.70,,,percent of total billed charges,,,1557.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OLEC LT ULNA 3H 65MM X_629343 X_STRYKER ORTH,10236122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3462.00,1038.60,1471.35,2942.70,,,,,,,,,,,,,service not payable,,,,,,,1746.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1471.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2596.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1731.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2596.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2942.70,,,percent of total billed charges,,,1592.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TWIST OFF 2X13MM,10236123,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1487.00,446.10,576.96,1263.95,,,,,,,,,,,,,,,,,,,,576.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1115.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,743.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.95,,,percent of total billed charges,,,669.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TWIST OFF 2X13MM,10236123,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1487.00,446.10,631.98,1263.95,,,,,,,,,,,,,service not payable,,,,,,,750.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,631.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1115.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,743.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1115.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1263.95,,,percent of total billed charges,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4H TI LK CRV 1.5MM,10236124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2560.00,768.00,993.28,2176.0,,,,,,,,,,,,,,,,,,,,993.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1920.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1280.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2176.0,,,percent of total billed charges,,,1152.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4H TI LK CRV 1.5MM,10236124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2560.00,768.00,1088.0,2176.0,,,,,,,,,,,,,service not payable,,,,,,,1291.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1088.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1920.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1280.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1920.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2176.0,,,percent of total billed charges,,,1177.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE .035 THREAD X_WT-0906STT X_ACUMED,10236125,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U4 2X220X150,10236126,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB STBplus  SZ3 15MM,10236128,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7364.00,2209.20,2857.23,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2857.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6259.40,,,percent of total billed charges,,,3313.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB STBplus  SZ3 15MM,10236128,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7364.00,2209.20,3092.88,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3714.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6259.40,,,percent of total billed charges,,,3387.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM DIST-LT SZ4 15MM X_5542-A-401 X_STRYKE,10236130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3903.00,1170.90,1514.36,3317.55,,,,,,,,,,,,,,,,,,,,1514.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2927.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1951.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.55,,,percent of total billed charges,,,1756.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM DIST-LT SZ4 15MM X_5542-A-401 X_STRYKE,10236130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3903.00,1170.90,1658.77,3317.55,,,,,,,,,,,,,service not payable,,,,,,,1968.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1658.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2927.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1951.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2927.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3317.55,,,percent of total billed charges,,,1795.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH HABIB BIPOLAR ENDOHPB RF,10236132,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,9491.00,2847.30,4033.68,8067.35,,5865.44,,,percent of total billed charges,,,,,,,,service not payable,4631.61,,,percent of total billed charges,,,4787.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4033.68,,,percent of total billed charges,,,,,,,,,7118.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4745.5,,,percent of total billed charges,,,,,,,,service not payable,7118.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8067.35,,,percent of total billed charges,,,4365.86,,,percent of total billed charges,,,,,,,,,6169.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6169.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EPIC BILIARY 8X100MM,10236133,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,5885.00,1765.50,2283.38,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2283.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5002.25,,,percent of total billed charges,,,2648.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EPIC BILIARY 8X100MM,10236133,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,5885.00,1765.50,2471.70,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2968.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5002.25,,,percent of total billed charges,,,2707.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EPIC BILIARY 8X60MM,10236134,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,5885.00,1765.50,2283.38,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2283.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5002.25,,,percent of total billed charges,,,2648.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EPIC BILIARY 8X60MM,10236134,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,5885.00,1765.50,2471.70,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2968.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5002.25,,,percent of total billed charges,,,2707.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP CANN FT 44X5MM LG X_AR-8750-44H X_ARTHR,10236135,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP CANN FT 44X5MM LG X_AR-8750-44H X_ARTHR,10236135,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Chg ANA Titer Reflex,10236147,CDM,0300,RC,86039,CPT,,,,,,outpatient,facility,,,23.00,6.90,10.58,25.22,,23.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.94,,,fee schedule,,,23.0,,,fee schedule,,,23.27,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,23.10,,,fee schedule,,,10.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.16,,,fee schedule,,,25.22,,,fee schedule,,,,,,,,,10.94,,,fee schedule,,,,,,,,,14.32,,,fee schedule,,,22.77,,,fee schedule,,,17.25,,,percent of total billed charges,,,10.94,,,fee schedule,,,10.6,,,fee schedule,,,11.16,,,fee schedule,,,16.85,,,fee schedule,,,10.94,,,fee schedule,,,17.25,,,percent of total billed charges,,,,,,,,,11.16,,,fee schedule,,,,,,,,,19.55,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,,,,,,,12.28,,,fee schedule,,,10.94,,,fee schedule,,,,,,,,,10.83,,,fee schedule,,,10.94,,,fee schedule,,,,,,,,,11.04,,,fee schedule,,,,,,,,
Chg ANA Titer Reflex,10236147,CDM,0300,RC,86039,CPT,394,EAPG,,,,outpatient,facility,,,23.00,6.90,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg dsDNA Titer Reflex,10236148,CDM,0300,RC,86256,CPT,,,,,,outpatient,facility,,,23.00,6.90,10.58,27.23,,23.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.81,,,fee schedule,,,19.18,,,fee schedule,,,25.13,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.94,,,fee schedule,,,11.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.05,,,fee schedule,,,27.23,,,fee schedule,,,,,,,,,11.81,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,24.58,,,fee schedule,,,17.25,,,percent of total billed charges,,,11.81,,,fee schedule,,,11.45,,,fee schedule,,,12.05,,,fee schedule,,,18.33,,,fee schedule,,,11.81,,,fee schedule,,,17.25,,,percent of total billed charges,,,,,,,,,12.05,,,fee schedule,,,,,,,,,19.55,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,,,,,,,13.26,,,fee schedule,,,11.81,,,fee schedule,,,,,,,,,11.69,,,fee schedule,,,11.81,,,fee schedule,,,,,,,,,11.93,,,fee schedule,,,,,,,,
Chg dsDNA Titer Reflex,10236148,CDM,0300,RC,86256,CPT,394,EAPG,,,,outpatient,facility,,,23.00,6.90,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Oklahoma Medical Research Foundation - Lupus Scree,10236149,CDM,0300,RC,86038,CPT,,,,,,outpatient,facility,,,33.00,9.90,11.49,33.0,,33.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.85,,,fee schedule,,,33.0,,,fee schedule,,,25.21,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,25.03,,,fee schedule,,,11.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.09,,,fee schedule,,,27.32,,,fee schedule,,,,,,,,,11.85,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,24.66,,,fee schedule,,,24.75,,,percent of total billed charges,,,11.85,,,fee schedule,,,11.49,,,fee schedule,,,12.09,,,fee schedule,,,18.33,,,fee schedule,,,11.85,,,fee schedule,,,24.75,,,percent of total billed charges,,,,,,,,,12.09,,,fee schedule,,,,,,,,,28.05,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,13.30,,,fee schedule,,,11.85,,,fee schedule,,,,,,,,,11.73,,,fee schedule,,,11.85,,,fee schedule,,,,,,,,,11.97,,,fee schedule,,,,,,,,
Oklahoma Medical Research Foundation - Lupus Scree,10236149,CDM,0300,RC,86038,CPT,394,EAPG,,,,outpatient,facility,,,33.00,9.90,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OMRF Lupus-Anti-dsDNA by Crithidia,10236201,CDM,0300,RC,86225,CPT,,,,,,outpatient,facility,,,56.00,16.80,13.05,56.0,,56.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.47,,,fee schedule,,,43.55,,,fee schedule,,,28.65,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.44,,,fee schedule,,,13.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.74,,,fee schedule,,,31.05,,,fee schedule,,,,,,,,,13.47,,,fee schedule,,,,,,,,,17.69,,,fee schedule,,,28.03,,,fee schedule,,,42.0,,,percent of total billed charges,,,13.47,,,fee schedule,,,13.05,,,fee schedule,,,13.74,,,fee schedule,,,20.81,,,fee schedule,,,13.47,,,fee schedule,,,42.0,,,percent of total billed charges,,,,,,,,,13.74,,,fee schedule,,,,,,,,,47.60,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,,,,,,,15.11,,,fee schedule,,,13.47,,,fee schedule,,,,,,,,,13.33,,,fee schedule,,,13.47,,,fee schedule,,,,,,,,,13.6,,,fee schedule,,,,,,,,
OMRF Lupus-Anti-dsDNA by Crithidia,10236201,CDM,0300,RC,86225,CPT,394,EAPG,,,,outpatient,facility,,,56.00,16.80,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OMRF Lupus-ENA by Precipitin,10236202,CDM,0300,RC,86235,CPT,,,,,,outpatient,facility,,,17.00,5.10,7.82,38.42,,17.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.66,,,fee schedule,,,17.0,,,fee schedule,,,37.39,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,35.19,,,fee schedule,,,17.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.99,,,fee schedule,,,38.42,,,fee schedule,,,,,,,,,16.66,,,fee schedule,,,,,,,,,23.16,,,fee schedule,,,34.68,,,fee schedule,,,12.75,,,percent of total billed charges,,,16.66,,,fee schedule,,,17.0,,,fee schedule,,,16.99,,,fee schedule,,,27.24,,,fee schedule,,,16.66,,,fee schedule,,,12.75,,,percent of total billed charges,,,,,,,,,16.99,,,fee schedule,,,,,,,,,14.45,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,19.72,,,fee schedule,,,16.66,,,fee schedule,,,,,,,,,17.39,,,fee schedule,,,16.66,,,fee schedule,,,,,,,,,16.66,,,fee schedule,,,,,,,,
OMRF Lupus-ENA by Precipitin,10236202,CDM,0300,RC,86235,CPT,394,EAPG,,,,outpatient,facility,,,17.00,5.10,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
AMNIOGRAFT AMNIOTIC 5.0X5.0CM,10236313,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4574.00,1372.20,1774.71,3887.90,,,,,,,,,,,,,,,,,,,,1774.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.90,,,percent of total billed charges,,,2058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMNIOGRAFT AMNIOTIC 5.0X5.0CM,10236313,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,,,,,,,,,,,,service not payable,,,,,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HIV 1/2 Antibody Differentiation,10236327,CDM,0300,RC,86701,CPT,,,,,,outpatient,facility,,,66.00,19.80,8.45,56.10,,28.45,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,8.71,,,fee schedule,,,21.23,,,fee schedule,,,18.54,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,18.40,,,fee schedule,,,8.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.88,,,fee schedule,,,20.09,,,fee schedule,,,,,,,,,8.71,,,fee schedule,,,,,,,,,11.38,,,fee schedule,,,18.14,,,fee schedule,,,49.5,,,percent of total billed charges,,,8.71,,,fee schedule,,,8.45,,,fee schedule,,,8.88,,,fee schedule,,,13.38,,,fee schedule,,,8.71,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,8.88,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,9.78,,,fee schedule,,,8.71,,,fee schedule,,,,,,,,,8.62,,,fee schedule,,,8.71,,,fee schedule,,,,,,,,,8.80,,,fee schedule,,,,,,,,
HIV 1/2 Antibody Differentiation,10236327,CDM,0300,RC,86701,CPT,394,EAPG,,,,outpatient,facility,,,66.00,19.80,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HIV 1/2 Antibody Differentiation-HIV-2,10236349,CDM,0300,RC,86702,CPT,,,,,,outpatient,facility,,,101.00,30.30,12.84,85.85,,28.42,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.25,,,fee schedule,,,21.20,,,fee schedule,,,28.20,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.99,,,fee schedule,,,12.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.52,,,fee schedule,,,30.56,,,fee schedule,,,,,,,,,13.25,,,fee schedule,,,,,,,,,17.27,,,fee schedule,,,27.58,,,fee schedule,,,75.75,,,percent of total billed charges,,,13.25,,,fee schedule,,,12.84,,,fee schedule,,,13.52,,,fee schedule,,,20.31,,,fee schedule,,,13.25,,,fee schedule,,,75.75,,,percent of total billed charges,,,,,,,,,13.52,,,fee schedule,,,,,,,,,85.85,,,percent of total billed charges,,,46.46,,,percent of total billed charges,,,,,,,,,14.87,,,fee schedule,,,13.25,,,fee schedule,,,,,,,,,13.11,,,fee schedule,,,13.25,,,fee schedule,,,,,,,,,13.39,,,fee schedule,,,,,,,,
HIV 1/2 Antibody Differentiation-HIV-2,10236349,CDM,0300,RC,86702,CPT,394,EAPG,,,,outpatient,facility,,,101.00,30.30,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Parvovirus B19 PCR,10236354,CDM,0300,RC,87798,CPT,,,,,,outpatient,facility,,,143.00,42.90,33.34,143.0,,143.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,107.25,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,107.25,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Parvovirus B19 PCR,10236354,CDM,0300,RC,87798,CPT,397,EAPG,,,,outpatient,facility,,,143.00,42.90,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COROENT ANT TLIF 10X14X40 8 DEG X_5104408 X_NUVASI,10236460,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,18686.00,5605.80,7250.17,15883.1,,9156.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7848.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7250.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7941.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14014.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9343.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15883.1,,,percent of total billed charges,,,8408.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 10X14X40 8 DEG X_5104408 X_NUVASI,10236460,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,18686.00,5605.80,7848.12,15883.1,,9156.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7848.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9425.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7941.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14014.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9343.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14014.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15883.1,,,percent of total billed charges,,,8595.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CORAIL REVISION HO 12,10236461,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,29265.00,8779.50,11354.82,24875.25,,14339.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12291.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11354.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12437.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21948.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14632.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24875.25,,,percent of total billed charges,,,13169.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CORAIL REVISION HO 12,10236461,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,29265.00,8779.50,12291.30,24875.25,,14339.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12291.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14761.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12437.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21948.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14632.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21948.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24875.25,,,percent of total billed charges,,,13461.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Herpes Simplex Virus Culture,10236629,CDM,0300,RC,87255,CPT,,,,,,outpatient,facility,,,82.00,24.60,32.17,82.0,,82.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,33.18,,,fee schedule,,,82.0,,,fee schedule,,,70.62,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,70.09,,,fee schedule,,,32.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",33.84,,,fee schedule,,,76.52,,,fee schedule,,,,,,,,,33.18,,,fee schedule,,,,,,,,,43.39,,,fee schedule,,,69.07,,,fee schedule,,,61.5,,,percent of total billed charges,,,33.18,,,fee schedule,,,32.17,,,fee schedule,,,33.84,,,fee schedule,,,51.03,,,fee schedule,,,33.18,,,fee schedule,,,61.5,,,percent of total billed charges,,,,,,,,,33.84,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,37.25,,,fee schedule,,,33.18,,,fee schedule,,,,,,,,,32.84,,,fee schedule,,,33.18,,,fee schedule,,,,,,,,,33.52,,,fee schedule,,,,,,,,
Herpes Simplex Virus Culture,10236629,CDM,0300,RC,87255,CPT,397,EAPG,,,,outpatient,facility,,,82.00,24.60,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Herpes Simplex Virus 1 DFA,10236642,CDM,0300,RC,87274,CPT,,,,,,outpatient,facility,,,57.00,17.10,11.38,50.96,,50.96,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.74,,,fee schedule,,,38.03,,,fee schedule,,,24.99,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.80,,,fee schedule,,,11.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.97,,,fee schedule,,,27.07,,,fee schedule,,,,,,,,,11.74,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,24.44,,,fee schedule,,,42.75,,,percent of total billed charges,,,11.74,,,fee schedule,,,11.38,,,fee schedule,,,11.97,,,fee schedule,,,18.33,,,fee schedule,,,11.74,,,fee schedule,,,42.75,,,percent of total billed charges,,,,,,,,,11.97,,,fee schedule,,,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,13.18,,,fee schedule,,,11.74,,,fee schedule,,,,,,,,,11.62,,,fee schedule,,,11.74,,,fee schedule,,,,,,,,,11.86,,,fee schedule,,,,,,,,
Herpes Simplex Virus 1 DFA,10236642,CDM,0300,RC,87274,CPT,396,EAPG,,,,outpatient,facility,,,57.00,17.10,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Herpes Simplex Virus 2 DFA,10236644,CDM,0300,RC,87273,CPT,,,,,,outpatient,facility,,,57.00,17.10,11.38,50.96,,50.96,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.74,,,fee schedule,,,38.03,,,fee schedule,,,24.99,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.80,,,fee schedule,,,11.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.97,,,fee schedule,,,27.07,,,fee schedule,,,,,,,,,11.74,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,24.44,,,fee schedule,,,42.75,,,percent of total billed charges,,,11.74,,,fee schedule,,,11.38,,,fee schedule,,,11.97,,,fee schedule,,,18.33,,,fee schedule,,,11.74,,,fee schedule,,,42.75,,,percent of total billed charges,,,,,,,,,11.97,,,fee schedule,,,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,13.18,,,fee schedule,,,11.74,,,fee schedule,,,,,,,,,11.62,,,fee schedule,,,11.74,,,fee schedule,,,,,,,,,11.86,,,fee schedule,,,,,,,,
Herpes Simplex Virus 2 DFA,10236644,CDM,0300,RC,87273,CPT,396,EAPG,,,,outpatient,facility,,,57.00,17.10,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT DES SIERRA 2.25X08MM RE,10236841,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X08MM RE,10236841,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X12MM RE,10236842,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X12MM RE,10236842,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X15MM RE,10236843,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X15MM RE,10236843,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X18MM RE,10236844,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X18MM RE,10236844,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X23MM RE,10236845,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X23MM RE,10236845,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X28MM RE,10236846,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X28MM RE,10236846,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X33MM RE,10236847,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X33MM RE,10236847,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.25X38MM RE,10236848,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.25X38MM RE,10236848,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X08MM RE,10236849,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X08MM RE,10236849,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X12MM RE,10236850,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X12MM RE,10236850,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X15MM RE,10236851,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X15MM RE,10236851,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X18MM RE,10236852,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X18MM RE,10236852,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X23MM RE,10236853,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X23MM RE,10236853,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X28MM RE,10236854,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X28MM RE,10236854,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X33MM RE,10236855,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X33MM RE,10236855,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.50X38MM RE,10236856,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.50X38MM RE,10236856,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X08MM RE,10236857,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X08MM RE,10236857,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X12MM RE,10236858,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X12MM RE,10236858,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X15MM RE,10236859,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X15MM RE,10236859,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X18MM RE,10236860,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X18MM RE,10236860,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X23MM RE,10236861,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X23MM RE,10236861,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X28MM RE,10236862,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X28MM RE,10236862,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X33MM RE,10236863,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X33MM RE,10236863,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 2.75X38MM RE,10236864,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 2.75X38MM RE,10236864,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X08MM RE,10236865,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X08MM RE,10236865,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X12MM RE,10236866,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X12MM RE,10236866,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X15MM RE,10236867,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X15MM RE,10236867,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X18MM RE,10236868,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X18MM RE,10236868,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X23MM RE,10236869,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X23MM RE,10236869,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X28MM RE,10236870,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X28MM RE,10236870,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X33MM RE,10236871,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X33MM RE,10236871,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.00X38MM RE,10236872,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.00X38MM RE,10236872,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X08MM RE X_1550325-08 X_ABBOT,10236873,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X08MM RE X_1550325-08 X_ABBOT,10236873,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X12MM RE,10236874,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X12MM RE,10236874,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X15MM RE,10236875,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X15MM RE,10236875,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X18MM RE,10236876,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X18MM RE,10236876,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X23MM RE,10236877,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X23MM RE,10236877,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X28MM RE,10236878,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X28MM RE,10236878,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X33MM RE,10236879,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X33MM RE,10236879,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.25X38MM RE,10236880,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.25X38MM RE,10236880,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X08MM RE,10236881,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X08MM RE,10236881,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X12MM RE,10236882,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X12MM RE,10236882,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X15MM RE,10236883,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X15MM RE,10236883,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X18MM RE,10236884,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X18MM RE,10236884,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X23MM RE,10236885,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X23MM RE,10236885,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X28MM RE,10236886,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X28MM RE,10236886,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X33MM RE,10236887,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X33MM RE,10236887,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 3.50X38MM RE,10236888,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 3.50X38MM RE,10236888,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X08MM RE,10236889,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X08MM RE,10236889,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X12MM RE,10236890,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X12MM RE,10236890,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X15MM RE,10236891,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X15MM RE,10236891,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X18MM RE,10236892,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X18MM RE,10236892,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X23MM RE,10236893,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X23MM RE,10236893,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X28MM RE,10236894,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X28MM RE,10236894,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X33MM RE,10236895,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X33MM RE,10236895,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT DES SIERRA 4.00X38MM RE,10236896,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3650.00,1095.00,1416.2,3102.5,,,,,,,,,,,,,,,,,,,,1416.2,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3102.5,,,percent of total billed charges,,,1642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT DES SIERRA 4.00X38MM RE,10236896,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3650.00,1095.00,1551.25,3102.5,,,,,,,,,,,,,service not payable,,,,,,,1841.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1551.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2737.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1825.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3102.5,,,percent of total billed charges,,,1679.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETER ASCERTA 4.8F 26CM,10236897,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETER ASCERTA 4.8F 26CM,10236897,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUG HALF BLK SZ3 10MM X_5546-A-301 X_STRYKE,10236899,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3318.00,995.40,1287.38,2820.30,,,,,,,,,,,,,,,,,,,,1287.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1410.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2488.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1659.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2820.30,,,percent of total billed charges,,,1493.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUG HALF BLK SZ3 10MM X_5546-A-301 X_STRYKE,10236899,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3318.00,995.40,1410.15,2820.30,,,,,,,,,,,,,service not payable,,,,,,,1673.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1410.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2488.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1659.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2488.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2820.30,,,percent of total billed charges,,,1526.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET CNSTRND 36X56MM 4,10237549,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15600.00,4680.00,6052.80,13260.0,,7644.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6552.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6052.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6630.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11700.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7800.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13260.0,,,percent of total billed charges,,,7020.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET CNSTRND 36X56MM 4,10237549,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15600.00,4680.00,6552.0,13260.0,,7644.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6552.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7868.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6630.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11700.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7800.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11700.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13260.0,,,percent of total billed charges,,,7176.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONTROLLER DOSAGE X_AF-DC-1 X_AIRXPANDERS,10237550,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,1716.00,514.80,729.30,1458.60,,1060.49,,,percent of total billed charges,,,,,,,,service not payable,837.41,,,percent of total billed charges,,,865.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,729.30,,,percent of total billed charges,,,,,,,,,1287.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,858.0,,,percent of total billed charges,,,,,,,,service not payable,1287.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1458.60,,,percent of total billed charges,,,789.36,,,percent of total billed charges,,,,,,,,,1115.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1115.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CERV 4 DEG W/PLUG 10MM X_77102104 X_STRY,10237551,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT CERV 4 DEG W/PLUG 10MM X_77102104 X_STRY,10237551,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB CLARIA MRI CRT D DF1,10237752,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,36475.00,10942.50,14152.30,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,14152.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31003.75,,,percent of total billed charges,,,16413.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB CLARIA MRI CRT D DF1,10237752,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,36475.00,10942.50,15319.5,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,18397.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31003.75,,,percent of total billed charges,,,16778.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BREAST TISSUE X_BR125-400 X_AIRXPANDERS,10237753,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,7659.00,2297.70,2971.69,6510.15,,3752.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3216.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2971.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3255.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5744.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3829.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6510.15,,,percent of total billed charges,,,3446.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BREAST TISSUE X_BR125-400 X_AIRXPANDERS,10237753,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,7659.00,2297.70,3216.78,6510.15,,3752.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3216.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3863.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3255.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5744.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3829.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5744.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6510.15,,,percent of total billed charges,,,3523.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12/14 TAPER CER 36MM X_71325174 X_SMITH N,10237754,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2410.00,723.00,935.08,2048.5,,,,,,,,,,,,,,,,,,,,935.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2048.5,,,percent of total billed charges,,,1084.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12/14 TAPER CER 36MM X_71325174 X_SMITH N,10237754,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2410.00,723.00,1024.25,2048.5,,,,,,,,,,,,,service not payable,,,,,,,1215.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1807.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1807.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2048.5,,,percent of total billed charges,,,1108.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FIXED 4.0X14MM,10238058,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FIXED 4.0X14MM,10238058,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ULN ELB ALLOY RT 3IN,10238060,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16063.00,4818.90,6232.44,13653.55,,7870.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6746.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6232.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6826.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12047.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8031.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13653.55,,,percent of total billed charges,,,7228.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ULN ELB ALLOY RT 3IN,10238060,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16063.00,4818.90,6746.46,13653.55,,7870.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6746.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8102.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6826.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12047.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8031.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12047.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13653.55,,,percent of total billed charges,,,7388.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE 45MM X_6200445 X_NUVASIVE,10238062,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,22024.00,6607.20,8545.31,18720.40,,10791.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9250.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8545.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9360.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16518.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11012.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18720.40,,,percent of total billed charges,,,9910.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE 45MM X_6200445 X_NUVASIVE,10238062,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,22024.00,6607.20,9250.08,18720.40,,10791.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9250.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11108.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9360.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16518.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11012.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16518.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18720.40,,,percent of total billed charges,,,10131.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR XTRA SMALL LT 10H,10238244,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3283.00,984.90,1273.80,2790.55,,,,,,,,,,,,,,,,,,,,1273.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2790.55,,,percent of total billed charges,,,1477.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR XTRA SMALL LT 10H,10238244,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3283.00,984.90,1395.27,2790.55,,,,,,,,,,,,,service not payable,,,,,,,1655.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2790.55,,,percent of total billed charges,,,1510.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.4X26MM X_656026 X_STRYKER ORTHOPAE,10238245,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.4X26MM X_656026 X_STRYKER ORTHOPAE,10238245,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.4X28MM X_656028 X_STRYKER ORTHOPAE,10238246,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.4X28MM X_656028 X_STRYKER ORTHOPAE,10238246,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2X32 EVOS X_7240-2032 X_SMITH NEPHEW,10238247,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2X32 EVOS X_7240-2032 X_SMITH NEPHEW,10238247,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Gentamicin Random,1024,CDM,0300,RC,80170,CPT,,,,,,outpatient,facility,,,196.00,58.80,15.56,166.60,,69.63,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.05,,,fee schedule,,,51.96,,,fee schedule,,,34.16,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,33.91,,,fee schedule,,,15.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.37,,,fee schedule,,,37.02,,,fee schedule,,,,,,,,,16.05,,,fee schedule,,,,,,,,,21.06,,,fee schedule,,,33.42,,,fee schedule,,,147.0,,,percent of total billed charges,,,16.05,,,fee schedule,,,15.56,,,fee schedule,,,16.37,,,fee schedule,,,24.77,,,fee schedule,,,16.05,,,fee schedule,,,147.0,,,percent of total billed charges,,,,,,,,,16.37,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,18.02,,,fee schedule,,,16.05,,,fee schedule,,,,,,,,,15.89,,,fee schedule,,,16.05,,,fee schedule,,,,,,,,,16.21,,,fee schedule,,,,,,,,
Gentamicin Random,1024,CDM,0300,RC,80170,CPT,405,EAPG,,,,outpatient,facility,,,196.00,58.80,14.30,137.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,116.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,66.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SL-< 6 hr Multiple Sleep Latency Test,10240134,CDM,0920,RC,95805,CPT,,,,,52  ,outpatient,facility,,,4005.00,1201.50,768.88,3404.25,,1030.43,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,768.88,,,fee schedule,,,2020.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1702.13,,,percent of total billed charges,,,,,,,,,3003.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2002.5,,,percent of total billed charges,,,,,,,,,3003.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3404.25,,,percent of total billed charges,,,1842.3,,,percent of total billed charges,,,,,,,,,2761.0,,,per diem,,,,,,,,,,,,,,,2430.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SL-< 6 hr Multiple Sleep Latency Test,10240134,CDM,0920,RC,95805,CPT,05723,APC,,,52  ,outpatient,facility,,,4005.00,1201.50,244.03,584.32,,,,,,,,254.41,,,fee schedule,,,,,,,,,,,,,,,535.20,,,fee schedule,,,244.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",259.5,,,fee schedule,,,584.32,,,fee schedule,,,,,,,,,254.41,,,fee schedule,,,,,,,,,,,,,,,527.44,,,fee schedule,,,,,,,,,254.41,,,fee schedule,,,244.03,,,fee schedule,,,259.5,,,fee schedule,,,,,,,,,254.41,,,fee schedule,,,,,,,,,244.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",259.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.41,,,fee schedule,,,,,,,,,,,,,,,254.41,,,fee schedule,,,,,,,,,256.95,,,fee schedule,,,,,,,,
SL-< 6 hr Multiple Sleep Latency Test,10240134,CDM,0920,RC,95805,CPT,222,EAPG,,,52  ,outpatient,facility,,,4005.00,1201.50,574.98,1795.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1795.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1526.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1128.09,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1240.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SL-< 6 hr Sleep Study unattended,10240137,CDM,0361,RC,G0399,HCPCS,,,,,,outpatient,facility,,,1189.00,356.70,505.32,1010.65,,734.80,,,percent of total billed charges,,,,,,,,,580.23,,,percent of total billed charges,,,599.73,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.32,,,percent of total billed charges,,,,,,,,,891.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,594.5,,,percent of total billed charges,,,,,,,,,891.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1010.65,,,percent of total billed charges,,,546.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SL-< 6 hr Sleep Study unattended,10240137,CDM,0361,RC,G0399,HCPCS,05721,APC,,,,outpatient,facility,,,1189.00,356.70,150.04,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
SL-< 6 hr Sleep Study unattended,10240137,CDM,0361,RC,G0399,HCPCS,226,EAPG,,,,outpatient,facility,,,1189.00,356.70,220.86,568.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,463.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,394.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,220.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,220.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,516.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,568.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SL-< 6 hr Sleep Study unattended,10240137,CDM,0920,RC,95806,CPT,,,,,52  ,outpatient,facility,,,1586.00,475.80,229.13,2511.0,,307.08,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,229.13,,,fee schedule,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,2511.0,,,per diem,,,,,,,,,,,,,,,2210.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SL-< 6 hr Sleep Study unattended,10240137,CDM,0920,RC,95806,CPT,05721,APC,,,52  ,outpatient,facility,,,1586.00,475.80,71.96,172.30,,,,,,,,75.02,,,fee schedule,,,,,,,,,,,,,,,157.82,,,fee schedule,,,71.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",76.52,,,fee schedule,,,172.30,,,fee schedule,,,,,,,,,75.02,,,fee schedule,,,,,,,,,,,,,,,155.53,,,fee schedule,,,,,,,,,75.02,,,fee schedule,,,71.96,,,fee schedule,,,76.52,,,fee schedule,,,,,,,,,75.02,,,fee schedule,,,,,,,,,71.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",76.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.02,,,fee schedule,,,,,,,,,,,,,,,75.02,,,fee schedule,,,,,,,,,75.76,,,fee schedule,,,,,,,,
SL-< 6 hr Sleep Study unattended,10240137,CDM,0920,RC,95806,CPT,226,EAPG,,,52  ,outpatient,facility,,,1586.00,475.80,110.43,284.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,197.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,258.23,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,284.05,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SL-< 6 hr Polysomnogram,10240140,CDM,0920,RC,95810,CPT,,,,,52  ,outpatient,facility,,,4005.00,1201.50,1064.76,3404.25,,1426.97,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1064.76,,,fee schedule,,,2020.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1702.13,,,percent of total billed charges,,,,,,,,,3003.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2002.5,,,percent of total billed charges,,,,,,,,,3003.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3404.25,,,percent of total billed charges,,,1842.3,,,percent of total billed charges,,,,,,,,,2761.0,,,per diem,,,,,,,,,,,,,,,2430.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SL-< 6 hr Polysomnogram,10240140,CDM,0920,RC,95810,CPT,05724,APC,,,52  ,outpatient,facility,,,4005.00,1201.50,467.91,1120.39,,,,,,,,487.82,,,fee schedule,,,,,,,,,,,,,,,1026.2,,,fee schedule,,,467.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",497.58,,,fee schedule,,,1120.39,,,fee schedule,,,,,,,,,487.82,,,fee schedule,,,,,,,,,,,,,,,1011.33,,,fee schedule,,,,,,,,,487.82,,,fee schedule,,,467.91,,,fee schedule,,,497.58,,,fee schedule,,,,,,,,,487.82,,,fee schedule,,,,,,,,,467.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",497.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.82,,,fee schedule,,,,,,,,,,,,,,,487.82,,,fee schedule,,,,,,,,,492.68,,,fee schedule,,,,,,,,
SL-< 6 hr Polysomnogram,10240140,CDM,0920,RC,95810,CPT,222,EAPG,,,52  ,outpatient,facility,,,4005.00,1201.50,574.98,1795.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1795.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1526.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1128.09,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1240.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SL-< 6 hr Polysomnogram w/CPAP,10240143,CDM,0920,RC,95811,CPT,,,,,52  ,outpatient,facility,,,4005.00,1201.50,1121.31,3404.25,,1502.75,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA SLEEP STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1121.31,,,fee schedule,,,2020.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1702.13,,,percent of total billed charges,,,,,,,,,3003.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2002.5,,,percent of total billed charges,,,,,,,,,3003.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3404.25,,,percent of total billed charges,,,1842.3,,,percent of total billed charges,,,,,,,,,2761.0,,,per diem,,,,,,,,,,,,,,,2430.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SL-< 6 hr Polysomnogram w/CPAP,10240143,CDM,0920,RC,95811,CPT,05724,APC,,,52  ,outpatient,facility,,,4005.00,1201.50,467.91,1120.39,,,,,,,,487.82,,,fee schedule,,,,,,,,,,,,,,,1026.2,,,fee schedule,,,467.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",497.58,,,fee schedule,,,1120.39,,,fee schedule,,,,,,,,,487.82,,,fee schedule,,,,,,,,,,,,,,,1011.33,,,fee schedule,,,,,,,,,487.82,,,fee schedule,,,467.91,,,fee schedule,,,497.58,,,fee schedule,,,,,,,,,487.82,,,fee schedule,,,,,,,,,467.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",497.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.82,,,fee schedule,,,,,,,,,,,,,,,487.82,,,fee schedule,,,,,,,,,492.68,,,fee schedule,,,,,,,,
SL-< 6 hr Polysomnogram w/CPAP,10240143,CDM,0920,RC,95811,CPT,222,EAPG,,,52  ,outpatient,facility,,,4005.00,1201.50,574.98,1795.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1795.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1526.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,574.98,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1128.09,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1240.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Newborn Scr NE GAA,10240262,CDM,0300,RC,82657,CPT,,,,,,outpatient,facility,,,12.00,3.60,5.52,46.24,,12.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.76,,,fee schedule,,,12.0,,,fee schedule,,,46.24,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.84,,,fee schedule,,,12.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.0,,,fee schedule,,,27.12,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,,28.65,,,fee schedule,,,24.48,,,fee schedule,,,9.0,,,percent of total billed charges,,,11.76,,,fee schedule,,,12.0,,,fee schedule,,,12.0,,,fee schedule,,,33.69,,,fee schedule,,,11.76,,,fee schedule,,,9.0,,,percent of total billed charges,,,,,,,,,12.0,,,fee schedule,,,,,,,,,10.20,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,24.39,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,21.5,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,
Newborn Scr NE GAA,10240262,CDM,0300,RC,82657,CPT,400,EAPG,,,,outpatient,facility,,,12.00,3.60,12.0,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Newborn Scr NE MPS-1,10240263,CDM,0300,RC,82657,CPT,,,,,,outpatient,facility,,,12.00,3.60,5.52,46.24,,12.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.76,,,fee schedule,,,12.0,,,fee schedule,,,46.24,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.84,,,fee schedule,,,12.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.0,,,fee schedule,,,27.12,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,,28.65,,,fee schedule,,,24.48,,,fee schedule,,,9.0,,,percent of total billed charges,,,11.76,,,fee schedule,,,12.0,,,fee schedule,,,12.0,,,fee schedule,,,33.69,,,fee schedule,,,11.76,,,fee schedule,,,9.0,,,percent of total billed charges,,,,,,,,,12.0,,,fee schedule,,,,,,,,,10.20,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,24.39,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,21.5,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,
Newborn Scr NE MPS-1,10240263,CDM,0300,RC,82657,CPT,400,EAPG,,,,outpatient,facility,,,12.00,3.60,12.0,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Newborn Scr NE X-ALD,10240264,CDM,0300,RC,82726,CPT,,,,,,outpatient,facility,,,12.00,3.60,5.52,41.19,,12.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.76,,,fee schedule,,,12.0,,,fee schedule,,,41.19,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.84,,,fee schedule,,,12.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.0,,,fee schedule,,,27.12,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,,25.28,,,fee schedule,,,24.48,,,fee schedule,,,9.0,,,percent of total billed charges,,,11.76,,,fee schedule,,,12.0,,,fee schedule,,,12.0,,,fee schedule,,,29.73,,,fee schedule,,,11.76,,,fee schedule,,,9.0,,,percent of total billed charges,,,,,,,,,12.0,,,fee schedule,,,,,,,,,10.20,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,21.73,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,19.16,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,
Newborn Scr NE X-ALD,10240264,CDM,0300,RC,82726,CPT,400,EAPG,,,,outpatient,facility,,,12.00,3.60,12.0,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE SUP MIDSHAFT 6H RT 75MM,10240278,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4188.00,1256.40,1624.94,3559.80,,,,,,,,,,,,,,,,,,,,1624.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1779.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3141.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2094.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3559.80,,,percent of total billed charges,,,1884.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SUP MIDSHAFT 6H RT 75MM,10240278,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4188.00,1256.40,1779.90,3559.80,,,,,,,,,,,,,service not payable,,,,,,,2112.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1779.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3141.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2094.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3141.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3559.80,,,percent of total billed charges,,,1926.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 10X60X130,10240280,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIS CLAV 12H 3.5MM LT X_70-0112 X_ACUMED,10240282,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4205.00,1261.50,1631.54,3574.25,,,,,,,,,,,,,,,,,,,,1631.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3574.25,,,percent of total billed charges,,,1892.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIS CLAV 12H 3.5MM LT X_70-0112 X_ACUMED,10240282,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4205.00,1261.50,1787.12,3574.25,,,,,,,,,,,,,service not payable,,,,,,,2121.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3574.25,,,percent of total billed charges,,,1934.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOSYNC DBM CHIPS 1-4MM 5ML X_ABS-2007-03 X_ARTHR,10240284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3016.00,904.80,1170.21,2563.60,,,,,,,,,,,,,,,,,,,,1170.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2262.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2563.60,,,percent of total billed charges,,,1357.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOSYNC DBM CHIPS 1-4MM 5ML X_ABS-2007-03 X_ARTHR,10240284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3016.00,904.80,1281.8,2563.60,,,,,,,,,,,,,service not payable,,,,,,,1521.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1281.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2262.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2262.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2563.60,,,percent of total billed charges,,,1387.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH QUICK CROSS 0.018 90CM 5F,10240285,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,941.00,282.30,399.93,799.85,,581.54,,,percent of total billed charges,,,,,,,,service not payable,459.21,,,percent of total billed charges,,,474.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,399.93,,,percent of total billed charges,,,,,,,,,705.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,470.5,,,percent of total billed charges,,,,,,,,service not payable,705.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,799.85,,,percent of total billed charges,,,432.86,,,percent of total billed charges,,,,,,,,,611.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,611.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH QUICK CROSS 0.035 90CM 6F,10240286,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,941.00,282.30,399.93,799.85,,581.54,,,percent of total billed charges,,,,,,,,service not payable,459.21,,,percent of total billed charges,,,474.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,399.93,,,percent of total billed charges,,,,,,,,,705.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,470.5,,,percent of total billed charges,,,,,,,,service not payable,705.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,799.85,,,percent of total billed charges,,,432.86,,,percent of total billed charges,,,,,,,,,611.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,611.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DILATION 12F 4X2X150CM,10240290,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1630.00,489.00,692.75,1385.5,,1007.34,,,percent of total billed charges,,,,,,,,service not payable,795.44,,,percent of total billed charges,,,822.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,692.75,,,percent of total billed charges,,,,,,,,,1222.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,815.0,,,percent of total billed charges,,,,,,,,service not payable,1222.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1385.5,,,percent of total billed charges,,,749.80,,,percent of total billed charges,,,,,,,,,1059.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1059.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KWIRE SS 1.2X150MM,10240291,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,57.00,17.10,22.12,48.45,,,,,,,,,,,,,,,,,,,,22.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.45,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KWIRE SS 1.2X150MM,10240291,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,57.00,17.10,24.22,48.45,,,,,,,,,,,,,service not payable,,,,,,,28.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,42.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,28.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,42.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROPATEN VASCULAR FEM 90CM/40CM X_HAX02A X_G,10240409,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,14159.00,4247.70,5493.69,12035.15,,6937.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5946.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5493.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6017.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10619.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7079.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12035.15,,,percent of total billed charges,,,6371.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROPATEN VASCULAR FEM 90CM/40CM X_HAX02A X_G,10240409,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,14159.00,4247.70,5946.78,12035.15,,6937.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5946.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7141.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6017.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10619.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7079.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10619.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12035.15,,,percent of total billed charges,,,6513.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN DIA 4X16MM X_48557416 X_STRYKER SPINE,10240410,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN DIA 4X16MM X_48557416 X_STRYKER SPINE,10240410,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN DIA 4X24MM X_48557424 X_STRYKER SPINE,10240411,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN DIA 4X24MM X_48557424 X_STRYKER SPINE,10240411,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHAFT FIBULAR 40MM X_77712040 X_STRYKER SPINE,10240412,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4209.00,1262.70,1633.09,3577.65,,,,,,,,,,,,,,,,,,,,1633.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3156.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2104.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3577.65,,,percent of total billed charges,,,1894.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAFT FIBULAR 40MM X_77712040 X_STRYKER SPINE,10240412,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4209.00,1262.70,1788.82,3577.65,,,,,,,,,,,,,service not payable,,,,,,,2123.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1788.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2104.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3577.65,,,percent of total billed charges,,,1936.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TI XIA 6.5X35MM X_48146535 X_STRYKER SPINE,10240413,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TI XIA 6.5X35MM X_48146535 X_STRYKER SPINE,10240413,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI XIA 4.5X70MM X_481321070 X_STRYKER SPINE,10240414,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI XIA 4.5X70MM X_481321070 X_STRYKER SPINE,10240414,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI XIA 4.5X60MM X_481321060 X_STRYKER SPINE,10240415,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI XIA 4.5X60MM X_481321060 X_STRYKER SPINE,10240415,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URET ASCERTA 4.8F 28CM,10240416,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URET ASCERTA 4.8F 28CM,10240416,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Anti Mullerian Hormone,10242164,CDM,0300,RC,82166,CPT,,,,,,outpatient,facility,,,67.00,20.10,30.82,87.28,,41.41,,,percent of total billed charges,,,37.85,,,fee schedule,,,32.96,,,fee schedule,,,80.54,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,79.94,,,fee schedule,,,36.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",38.61,,,fee schedule,,,87.28,,,fee schedule,,,,,,,,,37.85,,,fee schedule,,,,,,,,,54.18,,,fee schedule,,,78.78,,,fee schedule,,,50.25,,,percent of total billed charges,,,37.85,,,fee schedule,,,36.69,,,fee schedule,,,38.61,,,fee schedule,,,63.72,,,fee schedule,,,37.85,,,fee schedule,,,50.25,,,percent of total billed charges,,,,,,,,,38.61,,,fee schedule,,,,,,,,,56.95,,,percent of total billed charges,,,30.82,,,percent of total billed charges,,,,,,,,,42.48,,,fee schedule,,,37.85,,,fee schedule,,,,,,,,,37.46,,,fee schedule,,,37.85,,,fee schedule,,,,,,,,,38.23,,,fee schedule,,,,,,,,
Anti Mullerian Hormone,10242164,CDM,0300,RC,82166,CPT,400,EAPG,,,,outpatient,facility,,,67.00,20.10,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW POLY XIA3 8.5X50MM,10244099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA3 8.5X50MM,10244099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE XIA III TI RAD 80X6M,10244100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE XIA III TI RAD 80X6M,10244100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 9X80X75,10244103,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RESTR CEMENT BONE LF NOZ DISP,10244104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1059.00,317.70,410.89,900.15,,,,,,,,,,,,,,,,,,,,410.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,794.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,900.15,,,percent of total billed charges,,,476.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RESTR CEMENT BONE LF NOZ DISP,10244104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1059.00,317.70,450.07,900.15,,,,,,,,,,,,,service not payable,,,,,,,534.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,450.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,794.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,529.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,794.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,900.15,,,percent of total billed charges,,,487.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
I and D perianal abscess superficial,10244143,CDM,0490,RC,46050,CPT,,,,,,outpatient,facility,,,2639.00,791.70,1213.94,2912.34,,2639.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1331.11,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1979.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1979.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2243.15,,,percent of total billed charges,,,1213.94,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
I and D perianal abscess superficial,10244143,CDM,0490,RC,46050,CPT,05311,APC,,,,outpatient,facility,,,2639.00,791.70,838.61,2008.06,,,,,,,,874.30,,,fee schedule,,,,,,,,,,,,,,,1839.24,,,fee schedule,,,838.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",891.79,,,fee schedule,,,2008.06,,,fee schedule,,,,,,,,,874.30,,,fee schedule,,,,,,,,,,,,,,,1812.58,,,fee schedule,,,,,,,,,874.30,,,fee schedule,,,838.61,,,fee schedule,,,891.79,,,fee schedule,,,,,,,,,874.30,,,fee schedule,,,,,,,,,838.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",891.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,874.30,,,fee schedule,,,,,,,,,,,,,,,874.30,,,fee schedule,,,,,,,,,883.02,,,fee schedule,,,,,,,,
I and D perianal abscess superficial,10244143,CDM,0490,RC,46050,CPT,141,EAPG,,,,outpatient,facility,,,2639.00,791.70,2092.24,5987.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5987.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5089.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3000.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3300.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW FT LCKNG 2.7X18MM X_657018 X_STRYKER ORTHOPA,10244168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT LCKNG 2.7X18MM X_657018 X_STRYKER ORTHOPA,10244168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ASNIS PT 4X28MM X_604628 X_STRYKER ORTHOPAED,10244169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,773.00,231.90,299.92,657.05,,,,,,,,,,,,,,,,,,,,299.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,579.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.05,,,percent of total billed charges,,,347.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ASNIS PT 4X28MM X_604628 X_STRYKER ORTHOPAED,10244169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,773.00,231.90,328.52,657.05,,,,,,,,,,,,,service not payable,,,,,,,389.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,579.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,386.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,579.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.05,,,percent of total billed charges,,,355.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DYNANITE NITI 15X15,10244356,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYNANITE NITI 15X15,10244356,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DYN NITI 20WX20L X_AR-8719DS-2020 X_ARTHREX,10244357,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYN NITI 20WX20L X_AR-8719DS-2020 X_ARTHREX,10244357,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM SHOULDER 8X55MM,10244359,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM SHOULDER 8X55MM,10244359,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 36X64MM 4MM,10244360,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 36X64MM 4MM,10244360,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE NLCK 6H 4.5MM X_7182-9486 X_SMITH NEPHEW,10244361,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE NLCK 6H 4.5MM X_7182-9486 X_SMITH NEPHEW,10244361,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOC AKREOS AO 18.5 X_AO60P-18.5 X_BAUSCH AND,10244367,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 18.5 X_AO60P-18.5 X_BAUSCH AND,10244367,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLING SUPRIS MESH 1.1X60CM,10244370,CDM,0278,RC,C1771,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLING SUPRIS MESH 1.1X60CM,10244370,CDM,0278,RC,C1771,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL STRUT 19.5CM X_AT444FF X_ALAMO TISSUE SERV,10246098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL STRUT 19.5CM X_AT444FF X_ALAMO TISSUE SERV,10246098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRFT CRDIORT36X28X10X28MMX15CM,10246099,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,6042.00,1812.60,2344.30,5135.70,,2960.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2537.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2344.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2567.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4531.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3021.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5135.70,,,percent of total billed charges,,,2718.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRFT CRDIORT36X28X10X28MMX15CM,10246099,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,6042.00,1812.60,2537.64,5135.70,,2960.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2537.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3047.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2567.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4531.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3021.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4531.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5135.70,,,percent of total billed charges,,,2779.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR ALTRX 40X64MM,10246101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR ALTRX 40X64MM,10246101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETABULAR 54MM E,10246103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR 54MM E,10246103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ACRIS DUOFIX STD SZ3,10246106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ACRIS DUOFIX STD SZ3,10246106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
I and D ischiorectal and/or perirectal abscess,10246517,CDM,0490,RC,46040,CPT,,,,,,outpatient,facility,,,2858.00,857.40,1314.68,4917.20,,2858.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,1441.58,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,2143.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,2143.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2429.30,,,percent of total billed charges,,,1314.68,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
I and D ischiorectal and/or perirectal abscess,10246517,CDM,0490,RC,46040,CPT,05312,APC,,,,outpatient,facility,,,2858.00,857.40,1084.55,2596.92,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,2378.60,,,fee schedule,,,1084.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1153.3,,,fee schedule,,,2596.92,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,2344.12,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,1084.55,,,fee schedule,,,1153.3,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,1084.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1153.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,1141.95,,,fee schedule,,,,,,,,
I and D ischiorectal and/or perirectal abscess,10246517,CDM,0490,RC,46040,CPT,141,EAPG,,,,outpatient,facility,,,2858.00,857.40,2092.24,5987.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5987.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5089.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3000.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3300.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR KNOTLESS CORKSCREW X_AR-1941PS X_ARTHREX IN,10246539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR KNOTLESS CORKSCREW X_AR-1941PS X_ARTHREX IN,10246539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE GRAFT VITOSS 5ML MORSELS 1-4MM X_2102-0030 X_,10246541,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2209.00,662.70,857.09,1877.65,,,,,,,,,,,,,,,,,,,,857.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,938.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1656.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1104.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1877.65,,,percent of total billed charges,,,994.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE GRAFT VITOSS 5ML MORSELS 1-4MM X_2102-0030 X_,10246541,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2209.00,662.70,938.82,1877.65,,,,,,,,,,,,,service not payable,,,,,,,1114.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,938.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1656.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1104.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1656.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1877.65,,,percent of total billed charges,,,1016.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DRAINANGE 0.038INX40CM,10246547,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,337.43,,,percent of total billed charges,,,,,,,,service not payable,266.45,,,percent of total billed charges,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROCESSOR SUPER POWER 1 BAHA 5,10246548,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,12546.00,3763.80,4867.85,10664.1,,6147.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5269.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4867.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5332.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10664.1,,,percent of total billed charges,,,5645.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCESSOR SUPER POWER 1 BAHA 5,10246548,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,12546.00,3763.80,5269.32,10664.1,,6147.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5269.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6328.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5332.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10664.1,,,percent of total billed charges,,,5771.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO 5F 0.038X130CM,10246549,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,337.43,,,percent of total billed charges,,,,,,,,service not payable,266.45,,,percent of total billed charges,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG CABLE 5.0 2MM,10246677,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG CABLE 5.0 2MM,10246677,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKNG 5.0X12MM X_661312 X_STRYKER ORTHOPAEDI,10246678,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1496.00,448.80,580.45,1271.60,,,,,,,,,,,,,,,,,,,,580.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,748.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1271.60,,,percent of total billed charges,,,673.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKNG 5.0X12MM X_661312 X_STRYKER ORTHOPAEDI,10246678,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1496.00,448.80,635.80,1271.60,,,,,,,,,,,,,service not payable,,,,,,,754.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,635.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,748.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1122.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1271.60,,,percent of total billed charges,,,688.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 4.5X14MM X_661714 X_STRYKER ORTHOPAED,10246679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 4.5X14MM X_661714 X_STRYKER ORTHOPAED,10246679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SUP DEC 10H RT X_628030 X_STRYKER ORTHOPAEDI,10246680,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4654.00,1396.20,1805.75,3955.90,,,,,,,,,,,,,,,,,,,,1805.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1977.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3490.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2327.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3955.90,,,percent of total billed charges,,,2094.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SUP DEC 10H RT X_628030 X_STRYKER ORTHOPAEDI,10246680,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4654.00,1396.20,1977.95,3955.90,,,,,,,,,,,,,service not payable,,,,,,,2347.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1977.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3490.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2327.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3490.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3955.90,,,percent of total billed charges,,,2140.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB STRT 12H X_40-20812S X_STRYKER ORTHOPAED,10246681,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2298.00,689.40,891.62,1953.3,,,,,,,,,,,,,,,,,,,,891.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,976.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1723.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1149.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1953.3,,,percent of total billed charges,,,1034.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB STRT 12H X_40-20812S X_STRYKER ORTHOPAED,10246681,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2298.00,689.40,976.65,1953.3,,,,,,,,,,,,,service not payable,,,,,,,1159.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,976.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1723.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1149.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1723.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1953.3,,,percent of total billed charges,,,1057.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG COMP 14H 5.0MM X_627574 X_STRYKER ORTHO,10246682,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4982.00,1494.60,1933.02,4234.70,,,,,,,,,,,,,,,,,,,,1933.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2117.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3736.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2491.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4234.70,,,percent of total billed charges,,,2241.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG COMP 14H 5.0MM X_627574 X_STRYKER ORTHO,10246682,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4982.00,1494.60,2117.35,4234.70,,,,,,,,,,,,,service not payable,,,,,,,2512.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2117.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3736.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2491.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3736.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4234.70,,,percent of total billed charges,,,2291.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIBULA 8H X_AR-8943BR-08 X_ARTHREX INC,10246683,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIBULA 8H X_AR-8943BR-08 X_ARTHREX INC,10246683,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
XPOST 9.5X30MM 60DEG X_118-95630 X_EXTREMITY MEDIC,10246685,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8704.00,2611.20,3377.15,7398.40,,4264.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3655.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3377.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3699.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6528.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7398.40,,,percent of total billed charges,,,3916.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
XPOST 9.5X30MM 60DEG X_118-95630 X_EXTREMITY MEDIC,10246685,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8704.00,2611.20,3655.68,7398.40,,4264.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3655.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4390.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3699.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6528.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6528.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7398.40,,,percent of total billed charges,,,4003.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB 13H 3.5X223MM LT X_7180-1013 X_SMITH NEP,10246686,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3922.00,1176.60,1521.74,3333.70,,,,,,,,,,,,,,,,,,,,1521.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2941.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1961.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3333.70,,,percent of total billed charges,,,1764.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB 13H 3.5X223MM LT X_7180-1013 X_SMITH NEP,10246686,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3922.00,1176.60,1666.85,3333.70,,,,,,,,,,,,,service not payable,,,,,,,1978.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1666.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2941.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1961.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2941.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3333.70,,,percent of total billed charges,,,1804.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X65MM X_222865 X_SMITH NEPHEW,10246687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X65MM X_222865 X_SMITH NEPHEW,10246687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INFUS CRAGGMCNAMAR 5X100,10246688,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE STRAFIX 2X4CM,10246690,CDM,0278,RC,Q4133,HCPCS,,,,,,inpatient,facility,,,5917.00,1775.10,2295.80,5029.45,,2899.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2485.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2295.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2514.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4437.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2958.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5029.45,,,percent of total billed charges,,,2662.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE STRAFIX 2X4CM,10246690,CDM,0278,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,5917.00,1775.10,2485.14,5029.45,,2899.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2485.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2984.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2514.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4437.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2958.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4437.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5029.45,,,percent of total billed charges,,,2721.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE STRAFIX 2X4CM,10246690,CDM,0278,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,5917.00,1775.10,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL ACETABULAR 46MM 3H X_71335546 X_SMITH NEPHEW,10247036,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3427.00,1028.10,1329.68,2912.95,,,,,,,,,,,,,,,,,,,,1329.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.95,,,percent of total billed charges,,,1542.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR 46MM 3H X_71335546 X_SMITH NEPHEW,10247036,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3427.00,1028.10,1456.47,2912.95,,,,,,,,,,,,,service not payable,,,,,,,1728.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.95,,,percent of total billed charges,,,1576.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U8 X_U8130612 X_BARD,10247037,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE MED 600ML X_BR140-600 X_AIRXPANDER,10247039,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,7659.00,2297.70,2971.69,6510.15,,3752.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3216.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2971.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3255.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5744.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3829.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6510.15,,,percent of total billed charges,,,3446.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE MED 600ML X_BR140-600 X_AIRXPANDER,10247039,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,7659.00,2297.70,3216.78,6510.15,,3752.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3216.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3863.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3255.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5744.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3829.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5744.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6510.15,,,percent of total billed charges,,,3523.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE LG 800ML X_BR155-800 X_AIRXPANDERS,10247040,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,7659.00,2297.70,2971.69,6510.15,,3752.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3216.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2971.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3255.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5744.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3829.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6510.15,,,percent of total billed charges,,,3446.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE LG 800ML X_BR155-800 X_AIRXPANDERS,10247040,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,7659.00,2297.70,3216.78,6510.15,,3752.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3216.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3863.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3255.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5744.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3829.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5744.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6510.15,,,percent of total billed charges,,,3523.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST GEL MOD CLASSIC 130ML X_3507130MC X_M,10247042,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4284.00,1285.20,1662.19,3641.40,,,,,,,,,,,,,,,,,,,,1662.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3641.40,,,percent of total billed charges,,,1927.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST GEL MOD CLASSIC 130ML X_3507130MC X_M,10247042,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4284.00,1285.20,1820.7,3641.40,,,,,,,,,,,,,service not payable,,,,,,,2160.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3641.40,,,percent of total billed charges,,,1970.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VOICE PROSTHESIS 16F 6MM X_IN-1606-NS X_INHEALTH,10247047,CDM,0278,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VOICE PROSTHESIS 16F 6MM X_IN-1606-NS X_INHEALTH,10247047,CDM,0278,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,34.58,1231.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1086.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1086.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
SCREW LCKG AXSOS 5X14MM X_661114 X_STRYKER ORTHOPA,10247048,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG AXSOS 5X14MM X_661114 X_STRYKER ORTHOPA,10247048,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT MIDLINE PWR GLIDE 18G 10CM X_ST118101 X_353700,10247081,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,749.00,224.70,318.32,636.65,,462.88,,,percent of total billed charges,,,,,,,,service not payable,365.51,,,percent of total billed charges,,,377.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,318.32,,,percent of total billed charges,,,,,,,,,561.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,374.5,,,percent of total billed charges,,,,,,,,service not payable,561.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,344.54,,,percent of total billed charges,,,,,,,,,486.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,486.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ESOPHAGEAL WA FLEX 120CM,10248104,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7767.00,2330.10,3013.60,6601.95,,3805.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3262.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3013.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3300.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5825.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3883.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6601.95,,,percent of total billed charges,,,3495.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ESOPHAGEAL WA FLEX 120CM,10248104,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7767.00,2330.10,3262.14,6601.95,,3805.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3262.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3917.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3300.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5825.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3883.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5825.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6601.95,,,percent of total billed charges,,,3572.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEXALOBE 3.5X60MM,10248105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,799.00,239.70,310.01,679.15,,,,,,,,,,,,,,,,,,,,310.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,599.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,399.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,679.15,,,percent of total billed charges,,,359.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEXALOBE 3.5X60MM,10248105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,799.00,239.70,339.57,679.15,,,,,,,,,,,,,service not payable,,,,,,,403.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,339.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,599.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,399.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,599.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,679.15,,,percent of total billed charges,,,367.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TENDON SEMITENDINOSUS,10248106,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5436.00,1630.80,2109.17,4620.60,,2663.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2283.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2109.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2310.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4077.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2718.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4620.60,,,percent of total billed charges,,,2446.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TENDON SEMITENDINOSUS,10248106,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5436.00,1630.80,2283.12,4620.60,,2663.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2283.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2741.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2310.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4077.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2718.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4077.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4620.60,,,percent of total billed charges,,,2500.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL NL 3.5X30MM,10248107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL NL 3.5X30MM,10248107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL NL 3.5X34MM,10248108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL NL 3.5X34MM,10248108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT TI NL NS 3.5X34MM,10248109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT TI NL NS 3.5X34MM,10248109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL LOCK 3.5X60MM,10248110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL LOCK 3.5X60MM,10248110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL LOCK 3.5X56MM,10248111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL LOCK 3.5X56MM,10248111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTI-D LOCK 3.5X56MM,10248112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTI-D LOCK 3.5X56MM,10248112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX TIB LOCK 5H RT,10248113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7049.00,2114.70,2735.01,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2735.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5991.65,,,percent of total billed charges,,,3172.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX TIB LOCK 5H RT,10248113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7049.00,2114.70,2960.58,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3555.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5991.65,,,percent of total billed charges,,,3242.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7X40MM,10248116,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7X40MM,10248116,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE JOURNEY ST .014INX300CM X_M001391280 X_B,10248117,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,473.39,,,percent of total billed charges,,,,,,,,service not payable,373.81,,,percent of total billed charges,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,497.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,497.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OLECRANON EXT 5H RT 90MM X_70-0313 X_ACUMED,10248118,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4123.00,1236.90,1599.72,3504.55,,,,,,,,,,,,,,,,,,,,1599.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1752.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2061.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3504.55,,,percent of total billed charges,,,1855.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OLECRANON EXT 5H RT 90MM X_70-0313 X_ACUMED,10248118,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4123.00,1236.90,1752.27,3504.55,,,,,,,,,,,,,service not payable,,,,,,,2079.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1752.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3092.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2061.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3504.55,,,percent of total billed charges,,,1896.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RT- Art Line Procedure Charge,10248301,CDM,0490,RC,36620,CPT,,,,,,outpatient,facility,,,915.00,274.50,420.90,2912.34,,915.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,461.53,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,686.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,686.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,777.75,,,percent of total billed charges,,,420.90,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RT- Art Line Procedure Charge,10248301,CDM,0490,RC,36620,CPT,423,EAPG,,,,outpatient,facility,,,915.00,274.50,915.0,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,915.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,915.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH TRIALYSIS 12.5CM CURVED X_5615120 X_335839,10248431,CDM,0272,RC,C1752,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.23,864.45,,628.51,,,percent of total billed charges,,,,,,,,service not payable,496.30,,,percent of total billed charges,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.23,,,percent of total billed charges,,,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,661.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,661.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH ANSEL CHKFLO 8F 55CM,10248436,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,396.00,118.80,168.30,336.60,,244.73,,,percent of total billed charges,,,,,,,,service not payable,193.25,,,percent of total billed charges,,,199.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,168.30,,,percent of total billed charges,,,,,,,,,297.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,198.0,,,percent of total billed charges,,,,,,,,service not payable,297.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,336.60,,,percent of total billed charges,,,182.16,,,percent of total billed charges,,,,,,,,,257.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,257.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE FIXATION HAMMERTOE LG,10248437,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3784.00,1135.20,1468.19,3216.40,,,,,,,,,,,,,,,,,,,,1468.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1608.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2838.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1892.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3216.40,,,percent of total billed charges,,,1702.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE FIXATION HAMMERTOE LG,10248437,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3784.00,1135.20,1608.2,3216.40,,,,,,,,,,,,,service not payable,,,,,,,1908.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1608.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2838.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1892.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2838.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3216.40,,,percent of total billed charges,,,1740.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CODE FREEZE KIT X_KITCODEFREEZE X_344148,10248547,CDM,0270,RC,C1751,HCPCS,,,,,,outpatient,facility,,,690.00,207.00,293.25,586.5,,426.42,,,percent of total billed charges,,,,,,,,service not payable,336.72,,,percent of total billed charges,,,348.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,,,,,,,517.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,345.0,,,percent of total billed charges,,,,,,,,service not payable,517.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,586.5,,,percent of total billed charges,,,317.40,,,percent of total billed charges,,,,,,,,,448.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,448.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT VASC 16XMMX13.5CM,10248631,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15536.00,4660.80,6027.97,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6027.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13205.6,,,percent of total billed charges,,,6991.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT VASC 16XMMX13.5CM,10248631,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15536.00,4660.80,6525.12,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7836.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13205.6,,,percent of total billed charges,,,7146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BALLOON 5FR 40MMX130CM X_LX351305405F X_B,10248632,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,2533.18,,,percent of total billed charges,,,,,,,,service not payable,2000.31,,,percent of total billed charges,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP EZY KNEE X_10651-06 X_312991,10248822,CDM,0274,RC,L1846,HCPCS,,,,,,inpatient,facility,,,260.00,78.00,100.88,221.0,,,,,,,,,,,,,,,,,,,,100.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.0,,,percent of total billed charges,,,117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WRAP EZY KNEE X_10651-06 X_312991,10248822,CDM,0274,RC,L1846,HCPCS,,,,,,outpatient,facility,,,260.00,78.00,110.5,587.60,,,,,,,,255.84,,,fee schedule,,,,,,,,,131.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,538.20,,,fee schedule,,,260.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",260.96,,,fee schedule,,,587.60,,,fee schedule,,,,,,,,,255.84,,,fee schedule,,,,,,,,,110.5,,,percent of total billed charges,,Paid in addition to outpatient services ,530.40,,,fee schedule,,,195.0,,,percent of total billed charges,,,255.84,,,fee schedule,,,260.0,,,fee schedule,,,260.96,,,fee schedule,,,130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,255.84,,,fee schedule,,,195.0,,,percent of total billed charges,,,260.0,,,fee schedule,,,260.96,,,fee schedule,,,,,,,,,221.0,,,percent of total billed charges,,,119.60,,,percent of total billed charges,,,,,,,,,,,,,,,255.84,,,fee schedule,,,,,,,,,,,,,,,255.84,,,fee schedule,,,,,,,,,255.84,,,fee schedule,,,,,,,,
SCREW CANC 6X32MM X_608485 X_STRYKER ORTHOPAEDICS,10248909,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6X32MM X_608485 X_STRYKER ORTHOPAEDICS,10248909,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 10H LFT DIST LAT FEM X_627610 X_STRYKER ORTH,10248910,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6397.00,1919.10,2482.04,5437.45,,3134.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2686.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2482.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2718.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4797.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5437.45,,,percent of total billed charges,,,2878.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 10H LFT DIST LAT FEM X_627610 X_STRYKER ORTH,10248910,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6397.00,1919.10,2686.74,5437.45,,3134.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2686.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3226.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2718.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4797.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4797.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5437.45,,,percent of total billed charges,,,2942.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK AXSOS TI 5.0X20MM,10248911,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X20MM,10248911,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 5X26MM 135CM X_LSMU1350526 X_BARD,10248912,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 5X26MM 135CM X_LSMU1350526 X_BARD,10248912,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 5X37MM 135CM X_LSMU1350537 X_BARD,10248913,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 5X37MM 135CM X_LSMU1350537 X_BARD,10248913,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 6X37MM 135CM,10248914,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 6X37MM 135CM,10248914,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 7X26MM 135CM,10248915,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 7X26MM 135CM,10248915,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 7X37MM 135CM,10248916,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 7X37MM 135CM,10248916,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 9X38MM 135CM,10248917,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 9X38MM 135CM,10248917,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 9X58MM 135CM,10248918,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 9X58MM 135CM,10248918,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC BALLN 7X58MM 135CM,10248919,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC BALLN 7X58MM 135CM,10248919,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA SZ 2 12.5MM,10248920,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA SZ 2 12.5MM,10248920,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD SPRINT DF4 72CM X_6935M72 X_MEDTRONIC,10248921,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,6910.00,2073.00,2681.08,5873.5,,3385.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2902.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2681.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2936.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5182.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3455.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5873.5,,,percent of total billed charges,,,3109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD SPRINT DF4 72CM X_6935M72 X_MEDTRONIC,10248921,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,6910.00,2073.00,2902.20,5873.5,,3385.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2902.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3485.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2936.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5182.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3455.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5182.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5873.5,,,percent of total billed charges,,,3178.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP QUICK 6MM TO 4MM X_71067377 X_SMITH NEPHEW,10249064,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2486.00,745.80,964.57,2113.10,,,,,,,,,,,,,,,,,,,,964.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2113.10,,,percent of total billed charges,,,1118.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP QUICK 6MM TO 4MM X_71067377 X_SMITH NEPHEW,10249064,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,,,,,,,,,,,,service not payable,,,,,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP QUICK 10.5MM TO 6MM X_71067373 X_SMITH NEPHE,10249065,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2583.00,774.90,1002.20,2195.55,,,,,,,,,,,,,,,,,,,,1002.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1097.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1937.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1291.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2195.55,,,percent of total billed charges,,,1162.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP QUICK 10.5MM TO 6MM X_71067373 X_SMITH NEPHE,10249065,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2583.00,774.90,1097.77,2195.55,,,,,,,,,,,,,service not payable,,,,,,,1302.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1097.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1937.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1291.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1937.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2195.55,,,percent of total billed charges,,,1188.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN1/2 4MMX35MM X_71064358 X_SMITH NEPHEW,10249066,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,675.00,202.50,261.90,573.75,,,,,,,,,,,,,,,,,,,,261.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,506.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,337.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,573.75,,,percent of total billed charges,,,303.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN1/2 4MMX35MM X_71064358 X_SMITH NEPHEW,10249066,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,675.00,202.50,286.88,573.75,,,,,,,,,,,,,service not payable,,,,,,,340.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,286.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,506.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,337.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,506.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,573.75,,,percent of total billed charges,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ICD VISIA AF X_DVFB1D1 X_MEDTRONIC,10249067,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,23310.00,6993.00,9044.28,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9790.20,,,percent of total billed charges,,Paid in addition to inpatient services ,9044.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19813.5,,,percent of total billed charges,,,10489.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ICD VISIA AF X_DVFB1D1 X_MEDTRONIC,10249067,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,23310.00,6993.00,9790.20,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9790.20,,,percent of total billed charges,,Paid in addition to outpatient services ,11757.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19813.5,,,percent of total billed charges,,,10722.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM VERSA OFF 46X18X53MM,10249069,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM VERSA OFF 46X18X53MM,10249069,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE EVOS 5H 2.7MM Y-TINE X_72442782N X_SMITH NEP,10249070,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4072.00,1221.60,1579.94,3461.20,,,,,,,,,,,,,,,,,,,,1579.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1730.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3054.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2036.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3461.20,,,percent of total billed charges,,,1832.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE EVOS 5H 2.7MM Y-TINE X_72442782N X_SMITH NEP,10249070,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4072.00,1221.60,1730.60,3461.20,,,,,,,,,,,,,service not payable,,,,,,,2053.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1730.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3054.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2036.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3054.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3461.20,,,percent of total billed charges,,,1873.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7X13MM T8 X_72402713N X_SMITH,10249071,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7X13MM T8 X_72402713N X_SMITH,10249071,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7X17MM T8 X_72402717N X_SMITH,10249072,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7X17MM T8 X_72402717N X_SMITH,10249072,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 ST 2.7X11MM,10249073,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 ST 2.7X11MM,10249073,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 ST 2.7X12MM,10249074,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 ST 2.7X12MM,10249074,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR TOP SIDE LOADING X_48235011 X_STRYKER SP,10250124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR TOP SIDE LOADING X_48235011 X_STRYKER SP,10250124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATO POLY 6.5X45MM,10250125,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO POLY 6.5X45MM,10250125,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 9X25X4DEG X_48395094 X_STRYKER SPINE,10250126,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 9X25X4DEG X_48395094 X_STRYKER SPINE,10250126,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA SZ2.5 12.5MM,10250127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9844.00,2953.20,3819.47,8367.40,,4823.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4134.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3819.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4183.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7383.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4922.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8367.40,,,percent of total billed charges,,,4429.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA SZ2.5 12.5MM,10250127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9844.00,2953.20,4134.48,8367.40,,4823.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4134.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4965.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4183.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7383.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4922.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7383.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8367.40,,,percent of total billed charges,,,4528.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISS AXIS TUTOPLAST ALLO,10250130,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5925.00,1777.50,2298.90,5036.25,,2903.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2488.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2298.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2518.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4443.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2962.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5036.25,,,percent of total billed charges,,,2666.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISS AXIS TUTOPLAST ALLO,10250130,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5925.00,1777.50,2488.5,5036.25,,2903.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2488.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2988.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2518.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4443.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2962.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4443.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5036.25,,,percent of total billed charges,,,2725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VERASTURN F 190 HC WW X_1013317 X_ABBOTT,10250134,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VERSATURN F 190 PHC WW X_1013319 X_ABBOT,10250135,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VERSATURN F 190 HC J WW X_1013317J X_ABB,10250136,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VERSATURN F 190 PHC J WW X_1013319J X_AB,10250137,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN UL FLEX 190CM X_1044590 X_ABBO,10250138,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN UL FLEX 190CM J X_1044590J X_A,10250139,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE POWERTURN FLEX 190CM,10250140,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE POWERTURN FLEX 190CM J,10250141,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN 190CM X_1044594 X_ABBOTT LABOR,10250142,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN 190CM J X_1044594J X_ABBOTT LA,10250143,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN UL FLEX 300CM X_1044591 X_ABBO,10250144,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN UL FLEX 300CM J X_1044591J X_A,10250145,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN FLEX 300CM X_1044593 X_ABBOTT,10250146,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN FLEX 300CM J X_1044593J X_ABBO,10250147,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN 300CM X_1044595 X_ABBOTT LABOR,10250148,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE POWERTURN 300 CM J X_1044595J X_ABBOTT L,10250149,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC FLEX 190 HC WW X_1020009 X_ABBO,10250150,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC FLEX 190 PHC WW X_1020010 X_ABB,10250151,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC 190 HC WW X_1020013 X_ABBOTT LA,10250152,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE TURNTRAC 190 PHC WW,10250153,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC FLEX 300 HC WW X_1020011 X_ABBO,10250154,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC FLEX 300 PHC WW X_1020012 X_ABB,10250155,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC 300 HC WW X_1020015 X_ABBOTT LA,10250156,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TURNTRAC 300 PHC WW X_1020016 X_ABBOTT L,10250157,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP HEX 6.5MM 25MM,10250416,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP HEX 6.5MM 25MM,10250416,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP HEX 6.5MM 30MM,10250417,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP HEX 6.5MM 30MM,10250417,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP HEX 6.5MM 35MM,10250418,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP HEX 6.5MM 35MM,10250418,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIDENT II CLUSTERHOKE 52E,10250419,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 52E,10250419,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 135CM 5X150MM,10250422,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,10802.00,3240.60,4191.18,9181.70,,5292.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4536.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4191.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4590.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8101.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5401.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9181.70,,,percent of total billed charges,,,4860.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 135CM 5X150MM,10250422,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,10802.00,3240.60,4536.84,9181.70,,5292.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4536.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5448.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4590.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8101.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5401.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8101.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9181.70,,,percent of total billed charges,,,4968.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 1.5X20MMX150CM,10250423,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 2X40MMX150CM,10250424,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 2X60MMX150CM X_U415026RX X_CR BARD,10250425,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 2X100MMX150CM X_U4150210RX X_CR BA,10250426,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 2X200MMX150CM,10250427,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 2X300MMX150CM,10250428,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3X40MMX150CM,10250429,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3X60MMX150CM,10250430,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3X100MMX150CM,10250431,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3X200MMX150CM,10250432,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3X300MMX150CM,10250433,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 4X40MMX150CM,10250434,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 4X60MMX150CM,10250435,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 4X100MMX150CM,10250436,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 4X200MMX150CM,10250437,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 4X300MMX150CM,10250438,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 2.5X60MMX150CM X_U41502H6RX X_CR B,10250439,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 2.5X100MMX150CM,10250440,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 2.5X200MMX150CM,10250441,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 2.5X300MMX150CM,10250442,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 3.5X40MMX150CM,10250443,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 3.5X60MMX150CM,10250444,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 3.5X100MMX150CM,10250445,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3.5X200MMX150CM X_U41503H20RX X_CR,10250446,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERS 3.5X300MMX150CM,10250447,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 5X20MMX150CM,10250448,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 5X40MMX150CM,10250449,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 5X60MMX150CM,10250450,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 5X100MMX150CM,10250451,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 5X200MMX150CM,10250452,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 5X300MMX150CM,10250453,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 4X20MMX150CM,10250454,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAX 8.5X80MM X_482318580 X_STRYKER SPINE,10250455,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAX 8.5X80MM X_482318580 X_STRYKER SPINE,10250455,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 8X79MM 135CM,10250456,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4973.77,9947.55,,7232.45,,,percent of total billed charges,,,,,,,,service not payable,5711.06,,,percent of total billed charges,,,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,7606.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7606.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 11X79MM 135CM,10250762,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4973.77,9947.55,,7232.45,,,percent of total billed charges,,,,,,,,service not payable,5711.06,,,percent of total billed charges,,,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,7606.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7606.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS EXCLUDER X_CEB231210A X_GORE MEDICA,10250763,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24683.00,7404.90,9577.00,20980.55,,12094.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10366.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9577.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10490.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20980.55,,,percent of total billed charges,,,11107.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS EXCLUDER X_CEB231210A X_GORE MEDICA,10250763,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24683.00,7404.90,10366.86,20980.55,,12094.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10366.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12450.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10490.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20980.55,,,percent of total billed charges,,,11354.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ILIAC VAS 16MMX11.5CM,10250764,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15536.00,4660.80,6027.97,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6027.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13205.6,,,percent of total billed charges,,,6991.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ILIAC VAS 16MMX11.5CM,10250764,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15536.00,4660.80,6525.12,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7836.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13205.6,,,percent of total billed charges,,,7146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS EXCLUDER X_PLC181000 X_GORE MEDICAL,10250765,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15536.00,4660.80,6027.97,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6027.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13205.6,,,percent of total billed charges,,,6991.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS EXCLUDER X_PLC181000 X_GORE MEDICAL,10250765,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15536.00,4660.80,6525.12,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7836.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13205.6,,,percent of total billed charges,,,7146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ILIAC VAS 18MMX11.5CM,10250766,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15536.00,4660.80,6027.97,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6027.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13205.6,,,percent of total billed charges,,,6991.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ILIAC VAS 18MMX11.5CM,10250766,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15536.00,4660.80,6525.12,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7836.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13205.6,,,percent of total billed charges,,,7146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Hepatitis C Virus RNA Quant PCR,10252265,CDM,0300,RC,87522,CPT,,,,,,outpatient,facility,,,145.00,43.50,40.70,145.0,,145.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,41.98,,,fee schedule,,,135.82,,,fee schedule,,,89.35,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,88.68,,,fee schedule,,,40.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",42.82,,,fee schedule,,,96.82,,,fee schedule,,,,,,,,,41.98,,,fee schedule,,,,,,,,,55.18,,,fee schedule,,,87.39,,,fee schedule,,,108.75,,,percent of total billed charges,,,41.98,,,fee schedule,,,40.70,,,fee schedule,,,42.82,,,fee schedule,,,64.89,,,fee schedule,,,41.98,,,fee schedule,,,108.75,,,percent of total billed charges,,,,,,,,,42.82,,,fee schedule,,,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,47.12,,,fee schedule,,,41.98,,,fee schedule,,,,,,,,,41.55,,,fee schedule,,,41.98,,,fee schedule,,,,,,,,,42.40,,,fee schedule,,,,,,,,
Hepatitis C Virus RNA Quant PCR,10252265,CDM,0300,RC,87522,CPT,397,EAPG,,,,outpatient,facility,,,145.00,43.50,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Hepatitis C Virus RNA Quant PCR with Reflex to Gen,10252266,CDM,0300,RC,87522,CPT,,,,,,outpatient,facility,,,145.00,43.50,40.70,145.0,,145.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,41.98,,,fee schedule,,,135.82,,,fee schedule,,,89.35,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,88.68,,,fee schedule,,,40.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",42.82,,,fee schedule,,,96.82,,,fee schedule,,,,,,,,,41.98,,,fee schedule,,,,,,,,,55.18,,,fee schedule,,,87.39,,,fee schedule,,,108.75,,,percent of total billed charges,,,41.98,,,fee schedule,,,40.70,,,fee schedule,,,42.82,,,fee schedule,,,64.89,,,fee schedule,,,41.98,,,fee schedule,,,108.75,,,percent of total billed charges,,,,,,,,,42.82,,,fee schedule,,,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,47.12,,,fee schedule,,,41.98,,,fee schedule,,,,,,,,,41.55,,,fee schedule,,,41.98,,,fee schedule,,,,,,,,,42.40,,,fee schedule,,,,,,,,
Hepatitis C Virus RNA Quant PCR with Reflex to Gen,10252266,CDM,0300,RC,87522,CPT,397,EAPG,,,,outpatient,facility,,,145.00,43.50,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANN FT SM HEX 4X26MM,10252484,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT SM HEX 4X26MM,10252484,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB DIST 4H RT 74MM,10252485,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3803.00,1140.90,1475.56,3232.55,,,,,,,,,,,,,,,,,,,,1475.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1616.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2852.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1901.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3232.55,,,percent of total billed charges,,,1711.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB DIST 4H RT 74MM,10252485,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3803.00,1140.90,1616.27,3232.55,,,,,,,,,,,,,service not payable,,,,,,,1918.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1616.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2852.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1901.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2852.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3232.55,,,percent of total billed charges,,,1749.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATCH VASCULAR XENOSURE 1X14CM,10252486,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATCH VASCULAR XENOSURE 1X14CM,10252486,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH OMNI 1 5F 0.035INX80CM,10252487,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,149.56,,,percent of total billed charges,,,,,,,,service not payable,118.10,,,percent of total billed charges,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,157.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,157.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH OMNI 2 5F 0.035INX80CM,10252488,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,149.56,,,percent of total billed charges,,,,,,,,service not payable,118.10,,,percent of total billed charges,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,157.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,157.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL HIN XXSM,10252537,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12439.00,3731.70,4826.33,10573.15,,6095.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4826.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5286.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9329.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6219.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10573.15,,,percent of total billed charges,,,5597.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL HIN XXSM,10252537,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12439.00,3731.70,5224.38,10573.15,,6095.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6274.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5286.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9329.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6219.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9329.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10573.15,,,percent of total billed charges,,,5721.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH SAM 1 X_25-007-01-09 X_KLS MARTIN L P,10252538,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,8387.00,2516.10,3254.16,7128.95,,4109.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3522.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3254.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3564.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6290.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4193.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7128.95,,,percent of total billed charges,,,3774.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH SAM 1 X_25-007-01-09 X_KLS MARTIN L P,10252538,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,8387.00,2516.10,3522.54,7128.95,,4109.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3522.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4230.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3564.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6290.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4193.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6290.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7128.95,,,percent of total billed charges,,,3858.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4H RIGHT 68MM X_7282-0404 X_SMITH NEPHEW,10252539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3402.00,1020.60,1319.98,2891.70,,,,,,,,,,,,,,,,,,,,1319.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2551.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1701.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2891.70,,,percent of total billed charges,,,1530.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4H RIGHT 68MM X_7282-0404 X_SMITH NEPHEW,10252539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3402.00,1020.60,1445.85,2891.70,,,,,,,,,,,,,service not payable,,,,,,,1715.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1445.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2551.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1701.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2551.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2891.70,,,percent of total billed charges,,,1564.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO SOS 4F 0.035INX65CM,10252540,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB MOD SZ2,10254233,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11436.00,3430.80,4437.17,9720.60,,5603.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4803.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4437.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4860.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8577.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5718.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9720.60,,,percent of total billed charges,,,5146.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB MOD SZ2,10254233,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11436.00,3430.80,4803.12,9720.60,,5603.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4803.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5768.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4860.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8577.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5718.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8577.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9720.60,,,percent of total billed charges,,,5260.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE TIB MOD STP 15MM SZ2,10254234,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5717.00,1715.10,2218.20,4859.45,,2801.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2401.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2218.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2429.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4287.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2858.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4859.45,,,percent of total billed charges,,,2572.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE TIB MOD STP 15MM SZ2,10254234,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5717.00,1715.10,2401.14,4859.45,,2801.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2401.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2883.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2429.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4287.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2858.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4287.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4859.45,,,percent of total billed charges,,,2629.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB STBplus  SZ2 10MM,10254235,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7364.00,2209.20,2857.23,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2857.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6259.40,,,percent of total billed charges,,,3313.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB STBplus  SZ2 10MM,10254235,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7364.00,2209.20,3092.88,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3714.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6259.40,,,percent of total billed charges,,,3387.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB STBplus  SZ2 15MM,10254236,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7364.00,2209.20,2857.23,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2857.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6259.40,,,percent of total billed charges,,,3313.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB STBplus  SZ2 15MM,10254236,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7364.00,2209.20,3092.88,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3714.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6259.40,,,percent of total billed charges,,,3387.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 3X36MM,10254237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2720.00,816.00,1055.36,2312.0,,,,,,,,,,,,,,,,,,,,1055.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.0,,,percent of total billed charges,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 3X36MM,10254237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2720.00,816.00,1156.0,2312.0,,,,,,,,,,,,,service not payable,,,,,,,1371.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2040.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2040.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2312.0,,,percent of total billed charges,,,1251.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 3.5X55 X_657355 X_STRYKER ORTHOPAEDI,10254238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 3.5X55 X_657355 X_STRYKER ORTHOPAEDI,10254238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW V LK T10 FT 3.5X55MM,10254239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW V LK T10 FT 3.5X55MM,10254239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T10 FT 3.5X60MM,10254240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T10 FT 3.5X60MM,10254240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET 62MM G X_500-11-62G X_STRYKER ORTHOPAED,10254241,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET 62MM G X_500-11-62G X_STRYKER ORTHOPAED,10254241,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LOCKING 13X3.5MM,10254242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LOCKING 13X3.5MM,10254242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST RAD 3H LFT X_GMN-LTS-3HL X_SKELETAL DYN,10254245,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST RAD 3H LFT X_GMN-LTS-3HL X_SKELETAL DYN,10254245,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.5X20MM X_PALS-25200-CC X_SKELETAL DYN,10254247,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1006.00,301.80,390.33,855.10,,,,,,,,,,,,,,,,,,,,390.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,754.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,503.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,855.10,,,percent of total billed charges,,,452.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.5X20MM X_PALS-25200-CC X_SKELETAL DYN,10254247,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1006.00,301.80,427.55,855.10,,,,,,,,,,,,,service not payable,,,,,,,507.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,427.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,754.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,503.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,754.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,855.10,,,percent of total billed charges,,,462.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG THRD LCKG 2.3X19MM X_TPLS-23190-TS X_SKELETAL,10254248,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG THRD LCKG 2.3X19MM X_TPLS-23190-TS X_SKELETAL,10254248,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG THRD NON-LK 2.7X22MM X_TPNL-27220-TS X_SKELETA,10254249,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG THRD NON-LK 2.7X22MM X_TPNL-27220-TS X_SKELETA,10254249,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TORIC 16.0D SE X_ZCT22516.0 X_ABBOTT,10254250,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TORIC 16.0D SE X_ZCT22516.0 X_ABBOTT,10254250,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE POSTERIOR 535X35MM,10254251,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE POSTERIOR 535X35MM,10254251,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG AMPLATZER VASC II X_9-AVP2-022 X_AGA MEDICAL,10254252,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG AMPLATZER VASC II X_9-AVP2-022 X_AGA MEDICAL,10254252,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG VASC 14X18MM 9F,10254254,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG VASC 14X18MM 9F,10254254,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER ASPIRATION 3.5F 150CM X_CAT3 X_PENUMBRA I,10254256,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,3814.00,1144.20,1620.95,3241.90,,2357.05,,,percent of total billed charges,,,,,,,,service not payable,1861.23,,,percent of total billed charges,,,1923.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1620.95,,,percent of total billed charges,,,,,,,,,2860.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1907.0,,,percent of total billed charges,,,,,,,,service not payable,2860.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3241.90,,,percent of total billed charges,,,1754.44,,,percent of total billed charges,,,,,,,,,2479.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2479.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 4.5X35MM X_48144535 X_STRYKER SPINE,10254257,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 4.5X35MM X_48144535 X_STRYKER SPINE,10254257,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA TI 5.0X35MM X_48145035 X_STRYKER SPINE,10254258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA TI 5.0X35MM X_48145035 X_STRYKER SPINE,10254258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD BONE POSTERIOR 4.5 X 480MM,10254259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD BONE POSTERIOR 4.5 X 480MM,10254259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR CROSS SM X_48133224 X_STRYKER SPINE,10254260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR CROSS SM X_48133224 X_STRYKER SPINE,10254260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS EXCLUDER X_HGB161207A X_GORE MEDICA,10254261,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10333.00,3099.90,4009.20,8783.05,,5063.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4339.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4009.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4391.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7749.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5166.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8783.05,,,percent of total billed charges,,,4649.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS EXCLUDER X_HGB161207A X_GORE MEDICA,10254261,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10333.00,3099.90,4339.86,8783.05,,5063.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4339.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5211.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4391.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7749.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5166.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7749.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8783.05,,,percent of total billed charges,,,4753.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS EXCLUDER X_RLT261416 X_GORE MEDICAL,10254263,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,25257.00,7577.10,9799.72,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9799.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21468.45,,,percent of total billed charges,,,11365.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS EXCLUDER X_RLT261416 X_GORE MEDICAL,10254263,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,25257.00,7577.10,10607.94,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12739.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21468.45,,,percent of total billed charges,,,11618.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO DBM 1CC,10254272,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY BIO DBM 1CC,10254272,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO DBM 1CC,10254272,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,629.00,188.70,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 46C,10254273,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 46C,10254273,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIDENT II CLUSTERHOKE 48D,10254274,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 48D,10254274,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIDENT II CLUSTERHOKE 50D,10254275,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 50D,10254275,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIDENT II CLUSTERHOKE 56F,10254276,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 56F,10254276,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIDENT II CLUSTERHOKE 58F,10254277,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 58F,10254277,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TRI-II C-HOKE 60G,10254278,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRI-II C-HOKE 60G,10254278,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIDENT II CLUSTERHOKE 62G,10254279,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIDENT II CLUSTERHOKE 62G,10254279,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP HEX 6.5MM 15MM,10254280,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP HEX 6.5MM 15MM,10254280,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP HEX 6.5MM 20MM,10254281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP HEX 6.5MM 20MM,10254281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX LP 6.5X40MM X_7030-6540 X_STRYKER ORTHOP,10254282,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX LP 6.5X40MM X_7030-6540 X_STRYKER ORTHOP,10254282,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX LP 6.5X45MM X_7030-6545 X_STRYKER ORTHOP,10254283,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX LP 6.5X45MM X_7030-6545 X_STRYKER ORTHOP,10254283,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX LP 6.5X50MM X_7030-6550 X_STRYKER ORTHOP,10254284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX LP 6.5X50MM X_7030-6550 X_STRYKER ORTHOP,10254284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 6X59MM 135CM,10254286,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS 6X59MM 135CM,10254286,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 8X59MM 135CM,10254287,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS 8X59MM 135CM,10254287,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 15CMX6MM 120CM,10254288,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13408.00,4022.40,5202.30,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5202.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11396.80,,,percent of total billed charges,,,6033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS 15CMX6MM 120CM,10254288,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13408.00,4022.40,5631.36,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6763.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11396.80,,,percent of total billed charges,,,6167.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 15CMX7MM 120CM,10254289,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13408.00,4022.40,5202.30,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5202.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11396.80,,,percent of total billed charges,,,6033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS 15CMX7MM 120CM,10254289,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13408.00,4022.40,5631.36,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6763.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11396.80,,,percent of total billed charges,,,6167.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 5CMX8MM 120CM,10254290,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13408.00,4022.40,5202.30,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5202.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11396.80,,,percent of total billed charges,,,6033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS 5CMX8MM 120CM,10254290,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13408.00,4022.40,5631.36,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6763.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11396.80,,,percent of total billed charges,,,6167.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS 10CMX8MM 120CM,10254291,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13408.00,4022.40,5202.30,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5202.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11396.80,,,percent of total billed charges,,,6033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS 10CMX8MM 120CM,10254291,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13408.00,4022.40,5631.36,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6763.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11396.80,,,percent of total billed charges,,,6167.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TLSO FLEX RIGID PANEL OTS,10254716,CDM,0274,RC,L0450,HCPCS,,,,,,inpatient,facility,,,3359.00,1007.70,1303.29,2855.15,,,,,,,,,,,,,,,,,,,,1303.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1427.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2519.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1679.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2855.15,,,percent of total billed charges,,,1511.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TLSO FLEX RIGID PANEL OTS,10254716,CDM,0274,RC,L0450,HCPCS,,,,,,outpatient,facility,,,3359.00,1007.70,136.30,2855.15,,,,,,,,136.30,,,fee schedule,,,,,,,,,1694.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,286.74,,,fee schedule,,,,,,,,service not payable,139.03,,,fee schedule,,,313.06,,,fee schedule,,,,,,,,,136.30,,,fee schedule,,,,,,,,,1427.58,,,percent of total billed charges,,Paid in addition to outpatient services ,282.58,,,fee schedule,,,2519.25,,,percent of total billed charges,,,136.30,,,fee schedule,,,,,,,,service not payable,139.03,,,fee schedule,,,1679.5,,,percent of total billed charges,,Paid in addition to outpatient services ,136.30,,,fee schedule,,,2519.25,,,percent of total billed charges,,,,,,,,service not payable,139.03,,,fee schedule,,,,,,,,,2855.15,,,percent of total billed charges,,,1545.14,,,percent of total billed charges,,,,,,,,,,,,,,,136.30,,,fee schedule,,,,,,,,,,,,,,,136.30,,,fee schedule,,,,,,,,,137.67,,,fee schedule,,,,,,,,
GWIRE VASC WHOLEY 260CM,10254717,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VASC SIDEKICK 110CM,10256097,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VASC SIDEKICK 110CM X_SD110TG X_CR BARD INC,10256098,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1558.00,467.40,662.15,1324.3,,962.84,,,percent of total billed charges,,,,,,,,service not payable,760.30,,,percent of total billed charges,,,785.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,662.15,,,percent of total billed charges,,,,,,,,,1168.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,779.0,,,percent of total billed charges,,,,,,,,service not payable,1168.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1324.3,,,percent of total billed charges,,,716.68,,,percent of total billed charges,,,,,,,,,1012.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1012.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN BONE JURGAN BALL SYS SET,10256099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,930.00,279.00,360.84,790.5,,,,,,,,,,,,,,,,,,,,360.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN BONE JURGAN BALL SYS SET,10256099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,,,,,,,,,,,,service not payable,,,,,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT AXIOS EC 20MM,10256100,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,16375.00,4912.50,6353.5,13918.75,,8023.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6877.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6353.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6959.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12281.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8187.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13918.75,,,percent of total billed charges,,,7368.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT AXIOS EC 20MM,10256100,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,16375.00,4912.50,6877.5,13918.75,,8023.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6877.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8259.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6959.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12281.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8187.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12281.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13918.75,,,percent of total billed charges,,,7532.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.0X36MM X_30-0292 X_ACUMED,10256102,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.0X36MM X_30-0292 X_ACUMED,10256102,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BALLOON 100CM X_Q50-100P X_W L GORE,10256103,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2225.00,667.50,945.63,1891.25,,1375.05,,,percent of total billed charges,,,,,,,,service not payable,1085.8,,,percent of total billed charges,,,1122.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,945.63,,,percent of total billed charges,,,,,,,,,1668.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1112.5,,,percent of total billed charges,,,,,,,,service not payable,1668.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1891.25,,,percent of total billed charges,,,1023.5,,,percent of total billed charges,,,,,,,,,1446.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1446.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY ALLOSYNC DMB CB 5.0CC,10256106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3584.00,1075.20,1390.59,3046.40,,,,,,,,,,,,,,,,,,,,1390.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1523.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2688.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1792.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3046.40,,,percent of total billed charges,,,1612.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY ALLOSYNC DMB CB 5.0CC,10256106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3584.00,1075.20,1523.2,3046.40,,,,,,,,,,,,,service not payable,,,,,,,1807.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1523.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2688.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1792.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2688.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3046.40,,,percent of total billed charges,,,1648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIBERS DBM CORTICAL 5CC,10256107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIBERS DBM CORTICAL 5CC,10256107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE DYNANITE NITI 25X20,10258136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYNANITE NITI 25X20,10258136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LO PROF TI 6.7X85MM X_AR-8967-2885 X_ARTHREX,10258137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LO PROF TI 6.7X85MM X_AR-8967-2885 X_ARTHREX,10258137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE EXPANDABLE 10X28MM 6DEG X_541-0005 X_SPINEOLO,10258138,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE EXPANDABLE 10X28MM 6DEG X_541-0005 X_SPINEOLO,10258138,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH RESORB SMALL 51X51MM X_52-806-50-04 X_KLS MAR,10258139,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3698.00,1109.40,1434.82,3143.30,,,,,,,,,,,,,,,,,,,,1434.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1571.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1849.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3143.30,,,percent of total billed charges,,,1664.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH RESORB SMALL 51X51MM X_52-806-50-04 X_KLS MAR,10258139,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3698.00,1109.40,1571.65,3143.30,,,,,,,,,,,,,service not payable,,,,,,,1865.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1571.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2773.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1849.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2773.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3143.30,,,percent of total billed charges,,,1701.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SONICPIN RXG 2.1 X 4MM 5/CTG,10258142,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2499.00,749.70,969.61,2124.15,,,,,,,,,,,,,,,,,,,,969.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1874.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1249.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2124.15,,,percent of total billed charges,,,1124.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SONICPIN RXG 2.1 X 4MM 5/CTG,10258142,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2499.00,749.70,1062.08,2124.15,,,,,,,,,,,,,service not payable,,,,,,,1260.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1062.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1874.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1249.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1874.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2124.15,,,percent of total billed charges,,,1149.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MIX KIT DELIV BIOCARTILAGE SM,10258144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1339.00,401.70,519.53,1138.15,,,,,,,,,,,,,,,,,,,,519.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,,602.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIX KIT DELIV BIOCARTILAGE SM,10258144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1339.00,401.70,569.07,1138.15,,,,,,,,,,,,,service not payable,,,,,,,675.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,,615.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER ASPIRATION 135CM X_CAT6 X_PENUMBRA INC,10258145,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,6196.00,1858.80,2633.30,5266.60,,3829.13,,,percent of total billed charges,,,,,,,,service not payable,3023.65,,,percent of total billed charges,,,3125.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2633.30,,,percent of total billed charges,,,,,,,,,4647.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3098.0,,,percent of total billed charges,,,,,,,,service not payable,4647.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5266.60,,,percent of total billed charges,,,2850.16,,,percent of total billed charges,,,,,,,,,4027.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4027.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SINGLN7 SINGLE N7 PROCESSOR KT,10258148,CDM,0278,RC,L8627,HCPCS,,,,,,inpatient,facility,,,25128.00,7538.40,9749.66,21358.80,,12312.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10553.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9749.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10679.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12564.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21358.80,,,percent of total billed charges,,,11307.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SINGLN7 SINGLE N7 PROCESSOR KT,10258148,CDM,0278,RC,L8627,HCPCS,,,,,,outpatient,facility,,,25128.00,7538.40,5967.08,21358.80,,12312.72,,,percent of total billed charges,,Paid in addition to outpatient services ,8142.90,,,fee schedule,,,10553.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12674.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,17129.89,,,fee schedule,,,5967.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8305.76,,,fee schedule,,,18702.20,,,fee schedule,,,,,,,,,8142.90,,,fee schedule,,,,,,,,,10679.4,,,percent of total billed charges,,Paid in addition to outpatient services ,16881.63,,,fee schedule,,,18846.0,,,percent of total billed charges,,,8142.90,,,fee schedule,,,5967.08,,,fee schedule,,,8305.76,,,fee schedule,,,12564.0,,,percent of total billed charges,,Paid in addition to outpatient services ,8142.90,,,fee schedule,,,18846.0,,,percent of total billed charges,,,5967.08,,,fee schedule,,,8305.76,,,fee schedule,,,,,,,,,21358.80,,,percent of total billed charges,,,11558.88,,,percent of total billed charges,,,,,,,,,,,,,,,8142.90,,,fee schedule,,,,,,,,,,,,,,,8142.90,,,fee schedule,,,,,,,,,8224.33,,,fee schedule,,,,,,,,
SHEATH ENROUTE TRANSCAR 2.0,10258149,CDM,0272,RC,C1876,HCPCS,,,,,,outpatient,facility,,,10327.00,3098.10,4388.98,8777.95,,6382.09,,,percent of total billed charges,,,,,,,,service not payable,5039.58,,,percent of total billed charges,,,5208.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4388.98,,,percent of total billed charges,,,,,,,,,7745.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5163.5,,,percent of total billed charges,,,,,,,,service not payable,7745.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8777.95,,,percent of total billed charges,,,4750.42,,,percent of total billed charges,,,,,,,,,6712.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6712.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6X20MM TRANSCAR ENROUTE X_SR-0620-CS X_SILK,10258150,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6X20MM TRANSCAR ENROUTE X_SR-0620-CS X_SILK,10258150,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6X30MM TRANSCAR ENROUTE,10258151,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6X30MM TRANSCAR ENROUTE,10258151,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6X40MM TRANSCAR ENROUTE X_SR-0640-CS X_SILK,10258152,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6X40MM TRANSCAR ENROUTE X_SR-0640-CS X_SILK,10258152,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7X30MM TRANSCAR ENROUTE,10258153,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7X30MM TRANSCAR ENROUTE,10258153,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7X40MM TRANSCAR ENROUTE,10258154,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7X40MM TRANSCAR ENROUTE,10258154,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 8X30MM TRANSCAR ENROUTE,10258155,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 8X30MM TRANSCAR ENROUTE,10258155,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 8X40MM TRANSCAR ENROUTE,10258156,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 8X40MM TRANSCAR ENROUTE,10258156,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 9X30MM TRANSCAR ENROUTE,10258157,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 9X30MM TRANSCAR ENROUTE,10258157,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 9X40MM TRANSCAR ENROUTE,10258158,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 9X40MM TRANSCAR ENROUTE,10258158,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 10X30MM TRANSCAR ENROUTE,10258159,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 10X30MM TRANSCAR ENROUTE,10258159,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 10X40MM TRANSCAR ENROUTE,10258160,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 10X40MM TRANSCAR ENROUTE,10258160,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER MICRO KIT 4CM X_SR-4F21G4D-MP X_SILK RO,10258161,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.23,558.45,,406.03,,,percent of total billed charges,,,,,,,,service not payable,320.62,,,percent of total billed charges,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.23,,,percent of total billed charges,,,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER MICRO KIT 7CM,10258162,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.23,558.45,,406.03,,,percent of total billed charges,,,,,,,,service not payable,320.62,,,percent of total billed charges,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.23,,,percent of total billed charges,,,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 0.014 L 95CM ENROUTE,10258163,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,951.00,285.30,404.18,808.35,,587.72,,,percent of total billed charges,,,,,,,,service not payable,464.09,,,percent of total billed charges,,,479.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,404.18,,,percent of total billed charges,,,,,,,,,713.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,475.5,,,percent of total billed charges,,,,,,,,service not payable,713.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,808.35,,,percent of total billed charges,,,437.46,,,percent of total billed charges,,,,,,,,,618.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,618.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y-TINE EVOS 5H X_7244-2782 X_SMITH NEPHEW,10258164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4072.00,1221.60,1579.94,3461.20,,,,,,,,,,,,,,,,,,,,1579.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1730.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3054.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2036.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3461.20,,,percent of total billed charges,,,1832.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y-TINE EVOS 5H X_7244-2782 X_SMITH NEPHEW,10258164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4072.00,1221.60,1730.60,3461.20,,,,,,,,,,,,,service not payable,,,,,,,2053.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1730.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3054.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2036.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3054.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3461.20,,,percent of total billed charges,,,1873.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CTX T8 ST 2.7X13MM X_72402713 X_SMITH NEPHEW,10258165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CTX T8 ST 2.7X13MM X_72402713 X_SMITH NEPHEW,10258165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CTX T8 ST 2.7X17MM X_72402717 X_SMITH NEPHEW,10258166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CTX T8 ST 2.7X17MM X_72402717 X_SMITH NEPHEW,10258166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SS FT ST LK T8 2.7X11MM,10258167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SS FT ST LK T8 2.7X11MM,10258167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SS FT ST LK T8 2.7X12MM,10258168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,589.00,176.70,228.53,500.65,,,,,,,,,,,,,,,,,,,,228.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,441.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,294.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.65,,,percent of total billed charges,,,265.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SS FT ST LK T8 2.7X12MM,10258168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,589.00,176.70,250.32,500.65,,,,,,,,,,,,,service not payable,,,,,,,297.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,250.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,441.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,294.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,441.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,500.65,,,percent of total billed charges,,,270.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Adductor Canal Block,10258185,CDM,0360,RC,64447,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,5463.36,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Adductor Canal Block,10258185,CDM,0360,RC,64447,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Adductor Canal Block,10258185,CDM,0360,RC,64447,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ankle Block,10258186,CDM,0360,RC,64450,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,2912.34,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Ankle Block,10258186,CDM,0360,RC,64450,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Ankle Block,10258186,CDM,0360,RC,64450,CPT,214,EAPG,,,,outpatient,facility,,,1223.00,366.90,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Sciatic Nerve Block,10258187,CDM,0360,RC,64445,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block,10258187,CDM,0360,RC,64445,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Sciatic Nerve Block,10258187,CDM,0360,RC,64445,CPT,214,EAPG,,,,outpatient,facility,,,2202.00,660.60,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Axillary Nerve Block,10258188,CDM,0360,RC,64417,CPT,,,,,,outpatient,facility,,,1349.00,404.70,620.54,2912.34,,1349.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,680.44,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1011.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1011.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1146.65,,,percent of total billed charges,,,620.54,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Axillary Nerve Block,10258188,CDM,0360,RC,64417,CPT,05443,APC,,,,outpatient,facility,,,1349.00,404.70,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Axillary Nerve Block,10258188,CDM,0360,RC,64417,CPT,214,EAPG,,,,outpatient,facility,,,1349.00,404.70,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Thoracic Catheter,10258189,CDM,0360,RC,62324,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Thoracic Catheter,10258189,CDM,0360,RC,62324,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Thoracic Catheter,10258189,CDM,0360,RC,62324,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Femoral Nerve Block,10258190,CDM,0360,RC,64447,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,5463.36,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Femoral Nerve Block,10258190,CDM,0360,RC,64447,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Femoral Nerve Block,10258190,CDM,0360,RC,64447,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Interscalene /Supraclav.,10258191,CDM,0360,RC,64415,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,2912.34,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Interscalene /Supraclav.,10258191,CDM,0360,RC,64415,CPT,05443,APC,,,,outpatient,facility,,,1223.00,366.90,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Interscalene /Supraclav.,10258191,CDM,0360,RC,64415,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Arterial Line,10258192,CDM,0360,RC,36620,CPT,,,,,,outpatient,facility,,,840.00,252.00,386.40,2912.34,,840.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,423.70,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,630.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Arterial Line,10258192,CDM,0360,RC,36620,CPT,423,EAPG,,,,outpatient,facility,,,840.00,252.00,840.0,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,840.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,840.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CVP,10258193,CDM,0360,RC,36556,CPT,,,,,,outpatient,facility,,,3170.00,951.00,1458.2,3170.0,,3170.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1598.95,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CVP,10258193,CDM,0360,RC,36556,CPT,05183,APC,,,,outpatient,facility,,,3170.00,951.00,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
CVP,10258193,CDM,0360,RC,36556,CPT,75,EAPG,,,,outpatient,facility,,,3170.00,951.00,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Lumbar Catheter,10258194,CDM,0360,RC,62326,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Lumbar Catheter,10258194,CDM,0360,RC,62326,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Lumbar Catheter,10258194,CDM,0360,RC,62326,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TAP Block,10258195,CDM,0360,RC,64486,CPT,,,,,,outpatient,facility,,,605.00,181.50,278.30,3666.78,,605.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,3666.78,,,case rate,,,305.16,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,453.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,453.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,514.25,,,percent of total billed charges,,,278.30,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAP Block,10258195,CDM,0360,RC,64486,CPT,214,EAPG,,,,outpatient,facility,,,605.00,181.50,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Blood Patch,10258196,CDM,0360,RC,62273,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Blood Patch,10258196,CDM,0360,RC,62273,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Blood Patch,10258196,CDM,0360,RC,62273,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Emergency Intubation,10258197,CDM,0360,RC,31500,CPT,,,,,,outpatient,facility,,,597.00,179.10,274.62,2912.34,,597.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,301.13,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,447.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,447.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.45,,,percent of total billed charges,,,274.62,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Emergency Intubation,10258197,CDM,0360,RC,31500,CPT,05161,APC,,,,outpatient,facility,,,597.00,179.10,213.60,511.46,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,468.46,,,fee schedule,,,213.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",227.14,,,fee schedule,,,511.46,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,461.67,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,213.60,,,fee schedule,,,227.14,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,,,,,,,213.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",227.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,222.69,,,fee schedule,,,,,,,,,224.90,,,fee schedule,,,,,,,,
Emergency Intubation,10258197,CDM,0360,RC,31500,CPT,92,EAPG,,,,outpatient,facility,,,597.00,179.10,597.0,3274.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2783.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,597.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,597.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,597.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1839.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2023.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
U/S Guidance with Captured image,10258198,CDM,0402,RC,76942,CPT,,,,,,outpatient,facility,,,753.00,225.90,57.32,640.05,,76.82,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,57.32,,,fee schedule,,,379.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,320.02,,,percent of total billed charges,,,,,,,,,564.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,564.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,640.05,,,percent of total billed charges,,,346.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
U/S Guidance with Captured image,10258198,CDM,0402,RC,76942,CPT,472,EAPG,,,,outpatient,facility,,,753.00,225.90,163.60,422.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,359.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,315.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,347.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intrathecal Injection,10258199,CDM,0360,RC,62322,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Intrathecal Injection,10258199,CDM,0360,RC,62322,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Intrathecal Injection,10258199,CDM,0360,RC,62322,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Labor Epidural (59410 DX),10258200,CDM,0360,RC,62326,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Labor Epidural (59410 DX),10258200,CDM,0360,RC,62326,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Labor Epidural (59410 DX),10258200,CDM,0360,RC,62326,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL ACET PINN GRPTN 56MM,10258239,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET PINN GRPTN 56MM,10258239,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 5.0X46MM,10258241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 5.0X46MM,10258241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 7.0X80MM,10258242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 7.0X80MM,10258242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Adductor Canal Block,10258245,CDM,0360,RC,64447,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,5463.36,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Adductor Canal Block,10258245,CDM,0360,RC,64447,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Adductor Canal Block,10258245,CDM,0360,RC,64447,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ankle Block,10258246,CDM,0360,RC,64450,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,2912.34,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Ankle Block,10258246,CDM,0360,RC,64450,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Ankle Block,10258246,CDM,0360,RC,64450,CPT,214,EAPG,,,,outpatient,facility,,,1223.00,366.90,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Sciatic Nerve Block,10258247,CDM,0360,RC,64445,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block,10258247,CDM,0360,RC,64445,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Sciatic Nerve Block,10258247,CDM,0360,RC,64445,CPT,214,EAPG,,,,outpatient,facility,,,2202.00,660.60,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Axillary Nerve Block,10258248,CDM,0360,RC,64417,CPT,,,,,,outpatient,facility,,,1349.00,404.70,620.54,2912.34,,1349.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,680.44,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1011.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1011.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1146.65,,,percent of total billed charges,,,620.54,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Axillary Nerve Block,10258248,CDM,0360,RC,64417,CPT,05443,APC,,,,outpatient,facility,,,1349.00,404.70,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Axillary Nerve Block,10258248,CDM,0360,RC,64417,CPT,214,EAPG,,,,outpatient,facility,,,1349.00,404.70,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Thoracic Catheter,10258249,CDM,0360,RC,62324,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Thoracic Catheter,10258249,CDM,0360,RC,62324,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Thoracic Catheter,10258249,CDM,0360,RC,62324,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Femoral Nerve Block,10258250,CDM,0360,RC,64447,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,5463.36,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Femoral Nerve Block,10258250,CDM,0360,RC,64447,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Femoral Nerve Block,10258250,CDM,0360,RC,64447,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Interscalene /Supraclav.,10258251,CDM,0360,RC,64415,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,2912.34,,1223.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,616.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Interscalene /Supraclav.,10258251,CDM,0360,RC,64415,CPT,05443,APC,,,,outpatient,facility,,,1223.00,366.90,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Interscalene /Supraclav.,10258251,CDM,0360,RC,64415,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Arterial Line,10258252,CDM,0360,RC,36620,CPT,,,,,,outpatient,facility,,,840.00,252.00,386.40,2912.34,,840.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,423.70,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,630.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Arterial Line,10258252,CDM,0360,RC,36620,CPT,423,EAPG,,,,outpatient,facility,,,840.00,252.00,840.0,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,840.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,840.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CVP,10258253,CDM,0360,RC,36556,CPT,,,,,,outpatient,facility,,,3170.00,951.00,1458.2,3170.0,,3170.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1598.95,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CVP,10258253,CDM,0360,RC,36556,CPT,05183,APC,,,,outpatient,facility,,,3170.00,951.00,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
CVP,10258253,CDM,0360,RC,36556,CPT,75,EAPG,,,,outpatient,facility,,,3170.00,951.00,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Lumbar Catheter,10258254,CDM,0360,RC,62326,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Lumbar Catheter,10258254,CDM,0360,RC,62326,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Lumbar Catheter,10258254,CDM,0360,RC,62326,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TAP Block,10258255,CDM,0360,RC,64486,CPT,,,,,,outpatient,facility,,,605.00,181.50,278.30,3666.78,,605.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,3666.78,,,case rate,,,305.16,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,453.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,453.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,514.25,,,percent of total billed charges,,,278.30,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAP Block,10258255,CDM,0360,RC,64486,CPT,214,EAPG,,,,outpatient,facility,,,605.00,181.50,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Blood Patch,10258256,CDM,0360,RC,62273,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Blood Patch,10258256,CDM,0360,RC,62273,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Blood Patch,10258256,CDM,0360,RC,62273,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Emergency Intubation,10258257,CDM,0360,RC,31500,CPT,,,,,,outpatient,facility,,,597.00,179.10,274.62,2912.34,,597.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,301.13,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,447.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,447.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.45,,,percent of total billed charges,,,274.62,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Emergency Intubation,10258257,CDM,0360,RC,31500,CPT,05161,APC,,,,outpatient,facility,,,597.00,179.10,213.60,511.46,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,468.46,,,fee schedule,,,213.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",227.14,,,fee schedule,,,511.46,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,461.67,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,213.60,,,fee schedule,,,227.14,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,,,,,,,213.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",227.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,222.69,,,fee schedule,,,,,,,,,224.90,,,fee schedule,,,,,,,,
Emergency Intubation,10258257,CDM,0360,RC,31500,CPT,92,EAPG,,,,outpatient,facility,,,597.00,179.10,597.0,3274.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2783.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,597.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,597.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,597.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1839.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2023.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
U/S Guidance with Captured image,10258258,CDM,0402,RC,76942,CPT,,,,,,outpatient,facility,,,753.00,225.90,57.32,640.05,,76.82,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,57.32,,,fee schedule,,,379.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,320.02,,,percent of total billed charges,,,,,,,,,564.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,376.5,,,percent of total billed charges,,,,,,,,service not payable,564.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,640.05,,,percent of total billed charges,,,346.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
U/S Guidance with Captured image,10258258,CDM,0402,RC,76942,CPT,472,EAPG,,,,outpatient,facility,,,753.00,225.90,163.60,422.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,359.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,315.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,347.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intrathecal Injection,10258259,CDM,0360,RC,62322,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Intrathecal Injection,10258259,CDM,0360,RC,62322,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Intrathecal Injection,10258259,CDM,0360,RC,62322,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Labor Epidural (59410 DX),10258260,CDM,0360,RC,62326,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Labor Epidural (59410 DX),10258260,CDM,0360,RC,62326,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Labor Epidural (59410 DX),10258260,CDM,0360,RC,62326,CPT,53,EAPG,,,,outpatient,facility,,,2202.00,660.60,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Gentamicin Peak,1026,CDM,0300,RC,80170,CPT,,,,,,outpatient,facility,,,196.00,58.80,15.56,166.60,,69.63,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.05,,,fee schedule,,,51.96,,,fee schedule,,,34.16,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,33.91,,,fee schedule,,,15.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.37,,,fee schedule,,,37.02,,,fee schedule,,,,,,,,,16.05,,,fee schedule,,,,,,,,,21.06,,,fee schedule,,,33.42,,,fee schedule,,,147.0,,,percent of total billed charges,,,16.05,,,fee schedule,,,15.56,,,fee schedule,,,16.37,,,fee schedule,,,24.77,,,fee schedule,,,16.05,,,fee schedule,,,147.0,,,percent of total billed charges,,,,,,,,,16.37,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,18.02,,,fee schedule,,,16.05,,,fee schedule,,,,,,,,,15.89,,,fee schedule,,,16.05,,,fee schedule,,,,,,,,,16.21,,,fee schedule,,,,,,,,
Gentamicin Peak,1026,CDM,0300,RC,80170,CPT,405,EAPG,,,,outpatient,facility,,,196.00,58.80,14.30,137.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,116.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,66.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STAPLE DYN NITI 15WX15L X_AR-8719-1515 X_ARTHREX I,10266266,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYN NITI 15WX15L X_AR-8719-1515 X_ARTHREX I,10266266,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST HP 350-380CC,10266267,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST HP 350-380CC,10266267,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST HP 400-430CC,10266268,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST HP 400-430CC,10266268,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SPINE BIO AVS 9X25X15MM X_95015 X_STRYKER,10266270,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SPINE BIO AVS 9X25X15MM X_95015 X_STRYKER,10266270,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT HUMERAL 36/42 X_DWD988 X_TORNIER INC,10266271,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3704.00,1111.20,1437.15,3148.40,,,,,,,,,,,,,,,,,,,,1437.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1574.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2778.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1852.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3148.40,,,percent of total billed charges,,,1666.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT HUMERAL 36/42 X_DWD988 X_TORNIER INC,10266271,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3704.00,1111.20,1574.2,3148.40,,,,,,,,,,,,,service not payable,,,,,,,1868.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1574.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2778.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1852.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2778.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3148.40,,,percent of total billed charges,,,1703.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE STANDARD 42MM,10266272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8395.00,2518.50,3257.26,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3257.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7135.75,,,percent of total billed charges,,,3777.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE STANDARD 42MM,10266272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8395.00,2518.50,3525.90,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4234.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7135.75,,,percent of total billed charges,,,3861.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE GLENOID 25MM AEQUALI,10266273,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4741.00,1422.30,1839.51,4029.85,,,,,,,,,,,,,,,,,,,,1839.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3555.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2370.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4029.85,,,percent of total billed charges,,,2133.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE GLENOID 25MM AEQUALI,10266273,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4741.00,1422.30,2014.92,4029.85,,,,,,,,,,,,,service not payable,,,,,,,2391.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2014.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3555.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2370.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3555.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4029.85,,,percent of total billed charges,,,2180.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 6.5X40MM X_482616540 X_STRYKER,10266274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 6.5X40MM X_482616540 X_STRYKER,10266274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER PTA DILATATION 3MMX60X130 X_U3513036 X_BA,10266275,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE ANGLED .035X260,10266279,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1279.00,383.70,543.58,1087.15,,790.42,,,percent of total billed charges,,,,,,,,service not payable,624.15,,,percent of total billed charges,,,645.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,543.58,,,percent of total billed charges,,,,,,,,,959.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,639.5,,,percent of total billed charges,,,,,,,,service not payable,959.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1087.15,,,percent of total billed charges,,,588.34,,,percent of total billed charges,,,,,,,,,831.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,831.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE STRAIGHT .035X260,10266280,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1279.00,383.70,543.58,1087.15,,790.42,,,percent of total billed charges,,,,,,,,service not payable,624.15,,,percent of total billed charges,,,645.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,543.58,,,percent of total billed charges,,,,,,,,,959.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,639.5,,,percent of total billed charges,,,,,,,,service not payable,959.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1087.15,,,percent of total billed charges,,,588.34,,,percent of total billed charges,,,,,,,,,831.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,831.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN VBX 8X59MMX135CM,10266430,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN VBX 8X59MMX135CM,10266430,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABIL FEM 7MMX5X120CM,10266431,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABIL FEM 7MMX5X120CM,10266431,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 2.7X14MM X_72823114 X_SMITH NEPHEW,10266432,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,627.00,188.10,243.28,532.95,,,,,,,,,,,,,,,,,,,,243.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.95,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 2.7X14MM X_72823114 X_SMITH NEPHEW,10266432,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,627.00,188.10,266.47,532.95,,,,,,,,,,,,,service not payable,,,,,,,316.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,532.95,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 2.7X18MM X_72823118 X_SMITH NEPHEW,10266433,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,627.00,188.10,243.28,532.95,,,,,,,,,,,,,,,,,,,,243.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.95,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 2.7X18MM X_72823118 X_SMITH NEPHEW,10266433,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,627.00,188.10,266.47,532.95,,,,,,,,,,,,,service not payable,,,,,,,316.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,532.95,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 2.7X22MM X_72823122 X_SMITH NEPHEW,10266434,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,627.00,188.10,243.28,532.95,,,,,,,,,,,,,,,,,,,,243.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.95,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 2.7X22MM X_72823122 X_SMITH NEPHEW,10266434,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,627.00,188.10,266.47,532.95,,,,,,,,,,,,,service not payable,,,,,,,316.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,266.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,532.95,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VARIAX RT 8H 97MM,10266436,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4654.00,1396.20,1805.75,3955.90,,,,,,,,,,,,,,,,,,,,1805.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1977.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3490.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2327.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3955.90,,,percent of total billed charges,,,2094.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VARIAX RT 8H 97MM,10266436,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4654.00,1396.20,1977.95,3955.90,,,,,,,,,,,,,service not payable,,,,,,,2347.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1977.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3490.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2327.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3490.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3955.90,,,percent of total billed charges,,,2140.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ULTRAVERSE 3.5X20MMX150CM,10266437,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH PLATE 0.3MM SM 50X50X1MM,10266521,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3698.00,1109.40,1434.82,3143.30,,,,,,,,,,,,,,,,,,,,1434.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1571.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1849.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3143.30,,,percent of total billed charges,,,1664.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH PLATE 0.3MM SM 50X50X1MM,10266521,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3698.00,1109.40,1571.65,3143.30,,,,,,,,,,,,,service not payable,,,,,,,1865.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1571.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2773.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1849.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2773.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3143.30,,,percent of total billed charges,,,1701.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABIL COVERED 10MMX10CM X_VN1010040 X_GORE,10266522,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9372.00,2811.60,3636.34,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3636.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7966.20,,,percent of total billed charges,,,4217.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABIL COVERED 10MMX10CM X_VN1010040 X_GORE,10266522,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9372.00,2811.60,3936.24,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4727.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7966.20,,,percent of total billed charges,,,4311.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMCEM 5F RT 75X48MM X_NX031Z X_BRAUN MEDICAL,10266524,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMCEM 5F RT 75X48MM X_NX031Z X_BRAUN MEDICAL,10266524,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIBIA 14X52MM X_NX063Z X_BRAUN MEDICAL INC,10266525,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIBIA 14X52MM X_NX063Z X_BRAUN MEDICAL INC,10266525,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE PIN 2.7X40MM X_7117-1230 X_SMITH NEPHEW,10266526,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,634.00,190.20,245.99,538.90,,,,,,,,,,,,,,,,,,,,245.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,475.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,317.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.90,,,percent of total billed charges,,,285.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE PIN 2.7X40MM X_7117-1230 X_SMITH NEPHEW,10266526,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,634.00,190.20,269.45,538.90,,,,,,,,,,,,,service not payable,,,,,,,319.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,269.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,475.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,317.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,475.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,538.90,,,percent of total billed charges,,,291.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CORDIN DIL TREK 3.75X12MM 5F X_1012277-12 X_A,10266527,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE MASTERS HP VAVGJ 19MM,10266528,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,15901.00,4770.30,6169.59,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6169.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13515.85,,,percent of total billed charges,,,7155.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE MASTERS HP VAVGJ 19MM,10266528,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,15901.00,4770.30,6678.42,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8020.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13515.85,,,percent of total billed charges,,,7314.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE MIC 28FR GASTROSTOMY X_0100-28 X_133101,10266728,CDM,0272,RC,B4088,HCPCS,,,,,,outpatient,facility,,,169.00,50.70,71.83,193.11,,104.44,,,percent of total billed charges,,,,,,,,service not payable,82.47,,,percent of total billed charges,,,85.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,84.5,,,fee schedule,,,169.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,84.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,71.83,,,percent of total billed charges,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,service not payable,193.11,,,fee schedule,,,,,,,,,84.5,,,percent of total billed charges,,,,,,,,service not payable,126.75,,,percent of total billed charges,,,169.0,,,fee schedule,,,76.05,,,fee schedule,,,,,,,,,143.65,,,percent of total billed charges,,,77.74,,,percent of total billed charges,,,,,,,,,109.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,109.85,,,percent of total billed charges,,,84.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
TUBE MIC 28FR GASTROSTOMY X_0100-28 X_133101,10266728,CDM,0272,RC,B4088,HCPCS,498,EAPG,,,,outpatient,facility,,,169.00,50.70,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
VALVE TRACH SPEAKING AQUA X_PMV007 X_334511,10266796,CDM,0274,RC,L8501,HCPCS,,,,,,inpatient,facility,,,387.00,116.10,150.16,328.95,,,,,,,,,,,,,,,,,,,,150.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,290.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,,174.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRACH SPEAKING AQUA X_PMV007 X_334511,10266796,CDM,0274,RC,L8501,HCPCS,,,,,,outpatient,facility,,,387.00,116.10,91.24,328.95,,,,,,,,142.67,,,fee schedule,,,,,,,,,195.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,300.13,,,fee schedule,,,91.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",145.52,,,fee schedule,,,327.68,,,fee schedule,,,,,,,,,142.67,,,fee schedule,,,,,,,,,164.47,,,percent of total billed charges,,Paid in addition to outpatient services ,295.78,,,fee schedule,,,290.25,,,percent of total billed charges,,,142.67,,,fee schedule,,,91.24,,,fee schedule,,,145.52,,,fee schedule,,,193.5,,,percent of total billed charges,,Paid in addition to outpatient services ,142.67,,,fee schedule,,,290.25,,,percent of total billed charges,,,91.24,,,fee schedule,,,145.52,,,fee schedule,,,,,,,,,328.95,,,percent of total billed charges,,,178.02,,,percent of total billed charges,,,,,,,,,,,,,,,142.67,,,fee schedule,,,,,,,,,,,,,,,142.67,,,fee schedule,,,,,,,,,144.10,,,fee schedule,,,,,,,,
PLATE TIB T2 CR/PS CEM X_NN074Z X_AESCULAP,10268107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB T2 CR/PS CEM X_NN074Z X_AESCULAP,10268107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR CR SZ 7-8 15MM X_71453161 X_SMITH,10268108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR CR SZ 7-8 15MM X_71453161 X_SMITH,10268108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ2.5 15MM,10268109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ2.5 15MM,10268109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS AAA GORE X_PLL161207 X_GORE MEDICAL,10268110,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10605.00,3181.50,4114.74,9014.25,,5196.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4454.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4114.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4507.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7953.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5302.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9014.25,,,percent of total billed charges,,,4772.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS AAA GORE X_PLL161207 X_GORE MEDICAL,10268110,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10605.00,3181.50,4454.10,9014.25,,5196.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4454.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5349.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4507.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7953.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5302.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7953.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9014.25,,,percent of total billed charges,,,4878.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RECORDER LOOP CONFIRM RX ICM,10268111,CDM,0278,RC,C1764,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RECORDER LOOP CONFIRM RX ICM,10268111,CDM,0278,RC,C1764,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR COLUMBUS REV X_NR015Z X_B BRAUN MEDICAL,10268112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16883.00,5064.90,6550.60,14350.55,,8272.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7090.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6550.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7175.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12662.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8441.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14350.55,,,percent of total billed charges,,,7597.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR COLUMBUS REV X_NR015Z X_B BRAUN MEDICAL,10268112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16883.00,5064.90,7090.86,14350.55,,8272.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7090.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8515.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7175.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12662.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8441.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12662.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14350.55,,,percent of total billed charges,,,7766.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE TIBIA COLUMBUS REV X_NR052Z X_B BRAUN MEDICA,10268113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7917.00,2375.10,3071.80,6729.45,,3879.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3325.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3071.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3364.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5937.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3958.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6729.45,,,percent of total billed charges,,,3562.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE TIBIA COLUMBUS REV X_NR052Z X_B BRAUN MEDICA,10268113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7917.00,2375.10,3325.14,6729.45,,3879.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3325.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3993.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3364.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5937.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3958.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5937.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6729.45,,,percent of total billed charges,,,3641.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIA COLUMBUS REV X_NR076Z X_B BRAUN MEDICAL,10268114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14917.00,4475.10,5787.80,12679.45,,7309.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6265.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5787.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11187.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7458.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12679.45,,,percent of total billed charges,,,6712.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIA COLUMBUS REV X_NR076Z X_B BRAUN MEDICAL,10268114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14917.00,4475.10,6265.14,12679.45,,7309.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6265.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7524.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6339.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11187.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7458.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11187.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12679.45,,,percent of total billed charges,,,6861.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDE COLUMBUS REV 14MM X_NR132M X_B BRAUN MEDICAL,10268115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6622.00,1986.60,2569.34,5628.70,,3244.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2781.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2569.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4966.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3311.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5628.70,,,percent of total billed charges,,,2979.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDE COLUMBUS REV 14MM X_NR132M X_B BRAUN MEDICAL,10268115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6622.00,1986.60,2781.24,5628.70,,3244.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2781.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3340.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4966.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3311.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4966.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5628.70,,,percent of total billed charges,,,3046.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIBIA 15X192MM X_NR195Z X_B BRAUN MEDICAL,10268116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIBIA 15X192MM X_NR195Z X_B BRAUN MEDICAL,10268116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE TIBIA 5MM X_NR252Z X_B BRAUN MEDICAL,10268117,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7917.00,2375.10,3071.80,6729.45,,3879.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3325.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3071.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3364.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5937.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3958.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6729.45,,,percent of total billed charges,,,3562.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE TIBIA 5MM X_NR252Z X_B BRAUN MEDICAL,10268117,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7917.00,2375.10,3325.14,6729.45,,3879.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3325.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3993.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3364.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5937.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3958.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5937.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6729.45,,,percent of total billed charges,,,3641.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR 15X157 X_NR295Z X_B BRAUN MEDICAL,10268118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR 15X157 X_NR295Z X_B BRAUN MEDICAL,10268118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NUT FEMUR SZ NEUTR X_NR400Z X_B BRAUN MEDICAL,10268119,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NUT FEMUR SZ NEUTR X_NR400Z X_B BRAUN MEDICAL,10268119,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE FEM COLUMBUS REV 5MM X_NR465Z X_B BRAUN MEDI,10268120,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5738.00,1721.40,2226.34,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2226.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4877.30,,,percent of total billed charges,,,2582.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE FEM COLUMBUS REV 5MM X_NR465Z X_B BRAUN MEDI,10268120,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2409.96,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER FEM COLUMBUS REV 5MM X_NR565Z X_B BRAUN MED,10268121,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5738.00,1721.40,2226.34,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2226.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4877.30,,,percent of total billed charges,,,2582.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER FEM COLUMBUS REV 5MM X_NR565Z X_B BRAUN MED,10268121,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2409.96,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABIL COVERED 10MMX10CM X_VN10100040 X_GORE,10268123,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9372.00,2811.60,3636.34,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3636.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7966.20,,,percent of total billed charges,,,4217.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABIL COVERED 10MMX10CM X_VN10100040 X_GORE,10268123,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9372.00,2811.60,3936.24,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4727.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7966.20,,,percent of total billed charges,,,4311.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X20MMX130CM,10268124,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X20MMX130CM,10268124,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X40MMX130CM,10268125,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X40MMX130CM,10268125,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X60MMX130CM,10268126,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X60MMX130CM,10268126,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X80MMX130CM,10268127,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X80MMX130CM,10268127,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X100MMX130CM,10268128,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X100MMX130CM,10268128,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X120MMX130CM,10268129,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X120MMX130CM,10268129,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 5X150MMX130CM,10268130,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 5X150MMX130CM,10268130,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 6X20MMX130CM,10268131,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 6X20MMX130CM,10268131,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 6X40MMX130CM,10268132,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 6X40MMX130CM,10268132,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 6X60MMX130CM,10268133,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 6X60MMX130CM,10268133,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 6X80MMX130CM,10268134,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 6X80MMX130CM,10268134,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 6X100MMX130CM,10268135,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 6X100MMX130CM,10268135,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT INNOVA 6X120MMX130CM,10268136,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT INNOVA 6X120MMX130CM,10268136,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X20MMX130CM,10268137,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X20MMX130CM,10268137,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X40MMX130CM,10268138,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X40MMX130CM,10268138,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X60MMX130CM,10268139,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X60MMX130CM,10268139,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X80MMX130CM,10268140,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X80MMX130CM,10268140,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X100MMX130CM,10268141,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X100MMX130CM,10268141,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X120MMX130CM,10268142,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X120MMX130CM,10268142,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 7X150MMX130CM,10268143,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 7X150MMX130CM,10268143,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X20MMX130CM,10268144,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X20MMX130CM,10268144,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X40MMX130CM,10268145,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X40MMX130CM,10268145,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X60MMX130CM,10268146,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X60MMX130CM,10268146,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X80MMX130CM,10268147,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X80MMX130CM,10268147,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X100MMX130CM,10268148,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X100MMX130CM,10268148,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X120MMX130CM,10268149,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X120MMX130CM,10268149,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC PERIP 8X150MMX130CM,10268150,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC PERIP 8X150MMX130CM,10268150,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X40MMX75CM 6F,10268151,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X40MMX75CM 6F,10268151,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X60MMX75CM 6F,10268152,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X60MMX75CM 6F,10268152,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X80MMX75CM 6F,10268153,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X80MMX75CM 6F,10268153,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VAS EPIC 9X100MMX75CM 6F,10268154,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VAS EPIC 9X100MMX75CM 6F,10268154,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VAS EPIC 10X40MMX75CM 6F,10268155,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VAS EPIC 10X40MMX75CM 6F,10268155,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VAS EPIC 10X60MMX75CM 6F,10268156,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VAS EPIC 10X60MMX75CM 6F,10268156,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VAS EPIC 10X80MMX75CM 6F,10268157,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VAS EPIC 10X80MMX75CM 6F,10268157,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 10X100MMX75CM,10268158,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 10X100MMX75CM,10268158,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 12X40MMX75CM,10268159,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 12X40MMX75CM,10268159,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 12X60MMX75CM,10268160,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 12X60MMX75CM,10268160,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X40MMX120CM,10268161,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X40MMX120CM,10268161,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X60MMX120CM,10268162,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X60MMX120CM,10268162,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X80MMX120CM,10268163,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X80MMX120CM,10268163,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 9X100MMX120CM,10268164,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 9X100MMX120CM,10268164,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 10X40MMX120CM,10268165,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 10X40MMX120CM,10268165,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 10X60MMX120CM,10268166,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 10X60MMX120CM,10268166,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 10X80MMX120CM,10268167,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 10X80MMX120CM,10268167,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 10X100MMX120CM,10268168,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 10X100MMX120CM,10268168,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 12X40MMX120CM,10268169,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 12X40MMX120CM,10268169,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC EPIC 12X60MMX120CM,10268170,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC EPIC 12X60MMX120CM,10268170,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 10X30MMX75CM,10268171,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 10X30MMX75CM,10268171,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 10X60MMX75CM,10268172,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 10X60MMX75CM,10268172,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X20MMX75CM,10268173,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X20MMX75CM,10268173,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X30MMX75CM,10268174,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X30MMX75CM,10268174,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X40MMX75CM,10268175,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X40MMX75CM,10268175,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X60MMX75CM,10268176,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X60MMX75CM,10268176,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X20MMX75CM,10268177,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X20MMX75CM,10268177,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X27MMX75CM,10268178,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X27MMX75CM,10268178,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X37MMX75CM,10268179,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X37MMX75CM,10268179,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X60MMX75CM,10268180,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X60MMX75CM,10268180,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 7X27MMX75CM,10268181,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 7X27MMX75CM,10268181,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 7X37MMX75CM,10268182,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 7X37MMX75CM,10268182,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 7X57MMX75CM,10268183,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 7X57MMX75CM,10268183,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X17MMX75CM,10268184,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X17MMX75CM,10268184,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X27MMX75CM,10268185,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X27MMX75CM,10268185,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X57MMX75CM,10268186,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X57MMX75CM,10268186,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 9X25MMX75CM,10268187,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 9X25MMX75CM,10268187,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 9X37MMX75CM,10268188,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 9X37MMX75CM,10268188,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 9X57MMX75CM,10268189,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 9X57MMX75CM,10268189,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 10X25MMX135CM,10268190,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 10X25MMX135CM,10268190,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 10X37MMX135CM,10268191,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 10X37MMX135CM,10268191,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 7X27MMX135CM,10268192,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 7X27MMX135CM,10268192,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X27MMX135CM,10268193,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X27MMX135CM,10268193,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X37MMX135CM,10268194,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X37MMX135CM,10268194,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 5X57MMX135CM,10268195,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 5X57MMX135CM,10268195,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X20MMX135CM,10268196,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X20MMX135CM,10268196,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X27MMX135CM,10268197,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X27MMX135CM,10268197,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X37MMX135CM,10268198,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X37MMX135CM,10268198,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 6X57MMX135CM,10268199,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 6X57MMX135CM,10268199,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 7X17MMX135CM,10268200,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 7X17MMX135CM,10268200,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPR LD OTW 6FR 135CM,10268201,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPR LD OTW 6FR 135CM,10268201,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 7X57MMX135CM,10268202,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 7X57MMX135CM,10268202,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X17MMX135CM,10268203,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X17MMX135CM,10268203,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X27MMX135CM,10268204,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X27MMX135CM,10268204,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X40MMX135CM,10268205,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X40MMX135CM,10268205,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 8X57MMX135CM,10268206,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 8X57MMX135CM,10268206,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 9X25MMX135CM,10268207,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 9X25MMX135CM,10268207,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 9X37MMX135CM,10268208,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 9X37MMX135CM,10268208,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS LD 9X57MMX135CM,10268209,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS LD 9X57MMX135CM,10268209,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS SD 4X15MMX150CM,10268210,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS SD 4X15MMX150CM,10268210,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS SD 5X15MMX150CM,10268211,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS SD 5X15MMX150CM,10268211,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS SD 6X14MMX150CM,10268212,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS SD 6X14MMX150CM,10268212,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS SD 7X15MMX150CM,10268213,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS SD 7X15MMX150CM,10268213,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS SD 4X19MMX150CM,10268214,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS SD 4X19MMX150CM,10268214,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXPRESS SD 7X19MMX150CM,10268215,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3910.00,1173.00,1517.08,3323.5,,,,,,,,,,,,,,,,,,,,1517.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3323.5,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXPRESS SD 7X19MMX150CM,10268215,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3910.00,1173.00,1661.75,3323.5,,,,,,,,,,,,,service not payable,,,,,,,1972.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1661.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2932.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3323.5,,,percent of total billed charges,,,1798.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 1.5X20MMX142CM,10268216,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 1.5X40MMX150CM,10268217,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 1.5X40MMX142CM,10268218,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2X60MMX150CM,10268219,CDM,0278,RC,C1725,HCPCS,,,,,,inpatient,facility,,,1498.00,449.40,581.22,1273.3,,,,,,,,,,,,,,,,,,,,581.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,636.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,749.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1273.3,,,percent of total billed charges,,,674.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH COYOTE 2X60MMX150CM,10268219,CDM,0278,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,,,,,,,,,,,,service not payable,,,,,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2X80MMX150CM,10268220,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2X100MMX150CM,10268221,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2X120MMX150CM,10268222,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1870.00,561.00,794.75,1589.5,,1155.66,,,percent of total billed charges,,,,,,,,service not payable,912.56,,,percent of total billed charges,,,943.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,,,,,,,1402.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.0,,,percent of total billed charges,,,,,,,,service not payable,1402.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1589.5,,,percent of total billed charges,,,860.20,,,percent of total billed charges,,,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2X150MMX150CM,10268223,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1870.00,561.00,794.75,1589.5,,1155.66,,,percent of total billed charges,,,,,,,,service not payable,912.56,,,percent of total billed charges,,,943.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,,,,,,,1402.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.0,,,percent of total billed charges,,,,,,,,service not payable,1402.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1589.5,,,percent of total billed charges,,,860.20,,,percent of total billed charges,,,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2X220MMX150CM,10268224,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1870.00,561.00,794.75,1589.5,,1155.66,,,percent of total billed charges,,,,,,,,service not payable,912.56,,,percent of total billed charges,,,943.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,,,,,,,1402.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.0,,,percent of total billed charges,,,,,,,,service not payable,1402.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1589.5,,,percent of total billed charges,,,860.20,,,percent of total billed charges,,,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X20MMX143CM,10268225,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X40MMX145CM,10268226,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X60MMX150CM,10268227,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X80MMX150CM,10268228,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X100MMX150CM,10268229,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X120MMX150CM,10268230,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X150MMX150CM,10268231,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 2.5X220MMX150CM,10268232,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X20MMX143CM,10268233,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X40MMX145CM,10268234,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X60MMX150CM,10268235,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X80MMX150CM,10268236,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X100MMX150CM,10268237,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X120MMX150CM,10268238,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X150MMX150CM,10268239,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3X220MMX150CM,10268240,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X20MMX143CM,10268241,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X40MMX145CM,10268242,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X60MMX150CM,10268243,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X80MMX150CM,10268244,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X100MMX150CM,10268245,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X120MMX150CM,10268246,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X150MMX150CM,10268247,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 3.5X220MMX150CM,10268248,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1871.00,561.30,795.17,1590.35,,1156.28,,,percent of total billed charges,,,,,,,,service not payable,913.05,,,percent of total billed charges,,,943.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,795.17,,,percent of total billed charges,,,,,,,,,1403.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.5,,,percent of total billed charges,,,,,,,,service not payable,1403.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1590.35,,,percent of total billed charges,,,860.66,,,percent of total billed charges,,,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1216.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X20MMX143CM,10268249,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X40MMX145CM,10268250,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X60MMX150CM,10268251,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X80MMX150CM,10268252,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X100MMX150CM,10268253,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1498.00,449.40,636.65,1273.3,,925.76,,,percent of total billed charges,,,,,,,,service not payable,731.02,,,percent of total billed charges,,,755.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,,,,,,,1123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,749.0,,,percent of total billed charges,,,,,,,,service not payable,1123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1273.3,,,percent of total billed charges,,,689.08,,,percent of total billed charges,,,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,973.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X120MMX150CM,10268254,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X150MMX150CM,10268255,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1870.00,561.00,794.75,1589.5,,1155.66,,,percent of total billed charges,,,,,,,,service not payable,912.56,,,percent of total billed charges,,,943.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,,,,,,,1402.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.0,,,percent of total billed charges,,,,,,,,service not payable,1402.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1589.5,,,percent of total billed charges,,,860.20,,,percent of total billed charges,,,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH COYOTE 4X220MMX150CM,10268256,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1870.00,561.00,794.75,1589.5,,1155.66,,,percent of total billed charges,,,,,,,,service not payable,912.56,,,percent of total billed charges,,,943.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,,,,,,,1402.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,935.0,,,percent of total billed charges,,,,,,,,service not payable,1402.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1589.5,,,percent of total billed charges,,,860.20,,,percent of total billed charges,,,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1215.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X20MMX150CM,10268257,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X40MMX150CM,10268258,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X60MMX150CM,10268259,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X80MMX150CM,10268260,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X100MMX150CM,10268261,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X120MMX150CM,10268262,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 3X220MMX150CM,10268263,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X40MMX135CM,10268264,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X60MMX135CM,10268265,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X80MMX150CM,10268266,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X100MMX150CM,10268267,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X120MMX150CM,10268268,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X150MMX150CM,10268269,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 4X220MMX150CM,10268270,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X40MMX135CM,10268271,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X60MMX135CM,10268272,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X80MMX135CM,10268273,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X220X130 X_LX3513042205F X_CR BA,10268279,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2647.32,5294.65,,3849.52,,,percent of total billed charges,,,,,,,,service not payable,3039.75,,,percent of total billed charges,,,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,4048.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4048.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 5X220X130 PTA,10268280,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2647.32,5294.65,,3849.52,,,percent of total billed charges,,,,,,,,service not payable,3039.75,,,percent of total billed charges,,,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,4048.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4048.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 6X220X130PTA,10268281,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2647.32,5294.65,,3849.52,,,percent of total billed charges,,,,,,,,service not payable,3039.75,,,percent of total billed charges,,,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3114.5,,,percent of total billed charges,,,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,4048.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4048.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOC AKREOS AO 19.5 X_AO60P-19.5 X_BAUSCH AND,10268282,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 19.5 X_AO60P-19.5 X_BAUSCH AND,10268282,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X100MMX135CM,10268283,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X120MMX150CM,10268284,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X150MMX150CM,10268285,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 5X220MMX150CM,10268286,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X20MMX135CM,10268287,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X40MMX135CM,10268288,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X60MMX135CM,10268289,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X80MMX135CM,10268290,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X120MMX150CM,10268291,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X150MMX150CM,10268292,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 6X220MMX150CM,10268293,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X40MMX135CM,10268294,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X60MMX135CM,10268295,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X80MMX135CM,10268296,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X100MMX135CM,10268297,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X120MMX150CM,10268298,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X150MMX150CM,10268299,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING 7X220MMX150CM,10268300,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 3X20MMX135CM,10268301,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 3X40MMX135CM,10268302,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 3.5X20MMX135,10268303,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 3.5X40MMX135,10268304,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 4X20MMX135CM,10268305,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 4X40MMX135CM,10268306,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 4.5X40MMX135,10268307,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 5X20MMX135CM,10268308,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 5X40MMX135CM,10268309,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 5.5X20MMX135,10268310,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 5.5X40MMX135,10268311,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 6X20MMX135CM,10268312,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STERLING MR 6X40MMX135CM,10268313,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1632.00,489.60,693.60,1387.2,,1008.58,,,percent of total billed charges,,,,,,,,service not payable,796.42,,,percent of total billed charges,,,823.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.60,,,percent of total billed charges,,,,,,,,,1224.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,1224.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1387.2,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1060.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 3X20MMX75CM,10268314,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 3X40MMX75CM,10268315,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X20MMX75CM,10268316,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X40MMX75CM,10268317,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X20MMX75CM,10268318,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X40MMX75CM,10268319,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X60MMX75CM,10268320,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X80MMX75CM,10268321,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X20MMX75CM,10268322,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X40MMX75CM,10268323,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X60MMX75CM,10268324,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X80MMX75CM,10268325,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X100MMX75CM,10268326,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X20MMX75CM,10268327,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X40MMX75CM,10268328,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X60MMX75CM,10268329,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X80MMX75CM,10268330,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X100MMX75CM,10268331,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X20MMX75CM,10268332,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X30MMX75CM,10268333,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X40MMX75CM,10268334,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X60MMX75CM,10268335,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X80MMX75CM,10268336,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X100MMX75CM,10268337,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X20MMX75CM,10268338,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X30MMX75CM,10268339,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X40MMX75CM,10268340,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X60MMX75CM,10268341,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X80MMX75CM,10268342,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X20MMX75CM,10268343,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X30MMX75CM,10268344,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X40MMX75CM,10268345,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X60MMX75CM,10268346,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X20MMX75CM,10268347,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X30MMX75CM,10268348,CDM,0271,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X40MMX75CM,10268349,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X60MMX75CM,10268350,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 3X20MMX135CM,10268351,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 3X40MMX135CM,10268352,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X20MMX135CM,10268353,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X40MMX135CM,10268354,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X60MMX135CM,10268355,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X80MMX135CM,10268356,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X100MMX135CM,10268357,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X120MMX135CM,10268358,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X150MMX135CM,10268359,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 4X200MMX135CM,10268360,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X20MMX135CM,10268361,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X40MMX135CM,10268362,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X60MMX135CM,10268363,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X80MMX135CM,10268364,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X100MMX135CM,10268365,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 5X150MMX135CM,10268366,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X20MMX135CM,10268367,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X40MMX135CM,10268368,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X60MMX135CM,10268369,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X80MMX135CM,10268370,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X100MMX135CM,10268371,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X120MMX135CM,10268372,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X150MMX135CM,10268373,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X20MMX135CM,10268374,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X40MMX135CM,10268375,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X60MMX135CM,10268376,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X80MMX135CM,10268377,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X100MMX135CM,10268378,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X120MMX135CM,10268379,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X150MMX135CM,10268380,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 7X200MMX135CM,10268381,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X20MMX135CM,10268382,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X30MMX135CM,10268383,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X40MMX135CM,10268384,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X60MMX135CM,10268385,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X80MMX135CM,10268386,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X100MMX135CM,10268387,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X120MMX135CM,10268388,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X150MMX135CM,10268389,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 8X200MMX135CM,10268390,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X20MMX135CM,10268391,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X30MMX135CM,10268392,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X40MMX135CM,10268393,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X60MMX135CM,10268394,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 9X80MMX135CM,10268395,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X20MMX135CM,10268396,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X30MMX135CM,10268397,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X40MMX135CM,10268398,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X60MMX135CM,10268399,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 10X80MMX135CM,10268400,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X20MMX135CM,10268401,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X30MMX135CM,10268402,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X40MMX135CM,10268403,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 12X60MMX135CM,10268404,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PBC 5X20MMX135CM 6F,10268405,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3075.00,922.50,1306.88,2613.75,,1900.35,,,percent of total billed charges,,,,,,,,service not payable,1500.60,,,percent of total billed charges,,,1551.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1306.88,,,percent of total billed charges,,,,,,,,,2306.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1537.5,,,percent of total billed charges,,,,,,,,service not payable,2306.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2613.75,,,percent of total billed charges,,,1414.5,,,percent of total billed charges,,,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PBC 6X20MMX135CM 6F,10268406,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3075.00,922.50,1306.88,2613.75,,1900.35,,,percent of total billed charges,,,,,,,,service not payable,1500.60,,,percent of total billed charges,,,1551.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1306.88,,,percent of total billed charges,,,,,,,,,2306.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1537.5,,,percent of total billed charges,,,,,,,,service not payable,2306.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2613.75,,,percent of total billed charges,,,1414.5,,,percent of total billed charges,,,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PBC 7X20MMX135CM 6F,10268407,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3075.00,922.50,1306.88,2613.75,,1900.35,,,percent of total billed charges,,,,,,,,service not payable,1500.60,,,percent of total billed charges,,,1551.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1306.88,,,percent of total billed charges,,,,,,,,,2306.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1537.5,,,percent of total billed charges,,,,,,,,service not payable,2306.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2613.75,,,percent of total billed charges,,,1414.5,,,percent of total billed charges,,,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PBC 8X20MMX135CM 7F,10268408,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3075.00,922.50,1306.88,2613.75,,1900.35,,,percent of total billed charges,,,,,,,,service not payable,1500.60,,,percent of total billed charges,,,1551.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1306.88,,,percent of total billed charges,,,,,,,,,2306.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1537.5,,,percent of total billed charges,,,,,,,,service not payable,2306.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2613.75,,,percent of total billed charges,,,1414.5,,,percent of total billed charges,,,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS CEM SZ7 LT,10269103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS CEM SZ7 LT,10269103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB ROTATING CEM SZ5,10269104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17663.00,5298.90,6853.24,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6853.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15013.55,,,percent of total billed charges,,,7948.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB ROTATING CEM SZ5,10269104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17663.00,5298.90,7418.46,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8909.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15013.55,,,percent of total billed charges,,,8124.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATUN FEM SLV M/L 30MM FULL POR,10269105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11512.00,3453.60,4466.66,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4466.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9785.20,,,percent of total billed charges,,,5180.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATUN FEM SLV M/L 30MM FULL POR,10269105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11512.00,3453.60,4835.04,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5806.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9785.20,,,percent of total billed charges,,,5295.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB PRESSFIT STR 14X60MM,10269106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB PRESSFIT STR 14X60MM,10269106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE DIST FEM AUG SZ 7 4MM,10269107,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE DIST FEM AUG SZ 7 4MM,10269107,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR RP SZ7 14MM,10269108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR RP SZ7 14MM,10269108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BRG OXD ANATOMIC LT LG SZ7,10269109,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4722.00,1416.60,1832.14,4013.70,,,,,,,,,,,,,,,,,,,,1832.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2006.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3541.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2361.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4013.70,,,percent of total billed charges,,,2124.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRG OXD ANATOMIC LT LG SZ7,10269109,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4722.00,1416.60,2006.85,4013.70,,,,,,,,,,,,,service not payable,,,,,,,2381.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2006.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3541.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2361.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3541.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4013.70,,,percent of total billed charges,,,2172.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 7.5X40MM X_482617540 X_STRYKER,10269111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 7.5X40MM X_482617540 X_STRYKER,10269111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER OBLIQUE ALLOGRAFT 8X10X26MM X_804.008S X_GL,10269112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,13113.00,3933.90,5087.84,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5087.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,,5900.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER OBLIQUE ALLOGRAFT 8X10X26MM X_804.008S X_GL,10269112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5507.46,11146.05,,6425.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5507.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6556.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN 11.5MMX40CM RT X_71640740 X_SMITH NEPH,10269114,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10900.00,3270.00,4229.20,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4229.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9265.0,,,percent of total billed charges,,,4905.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN 11.5MMX40CM RT X_71640740 X_SMITH NEPH,10269114,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10900.00,3270.00,4578.0,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5497.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9265.0,,,percent of total billed charges,,,5014.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE SZ6N LT,10269116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE SZ6N LT,10269116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3.5MM 11H 191MM X_7180-1411 X_SMITH NEPHEW,10269117,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4174.00,1252.20,1619.51,3547.90,,,,,,,,,,,,,,,,,,,,1619.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1773.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3130.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2087.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3547.90,,,percent of total billed charges,,,1878.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3.5MM 11H 191MM X_7180-1411 X_SMITH NEPHEW,10269117,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4174.00,1252.20,1773.95,3547.90,,,,,,,,,,,,,service not payable,,,,,,,2105.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1773.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3130.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2087.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3130.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3547.90,,,percent of total billed charges,,,1920.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VNTRLGHT ST ECHO PS 6IN,10269118,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VNTRLGHT ST ECHO PS 6IN,10269118,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACK GRAFT BONE HV CEMENT 20G,10269119,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1699.00,509.70,659.21,1444.15,,,,,,,,,,,,,,,,,,,,659.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1274.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,849.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1444.15,,,percent of total billed charges,,,764.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACK GRAFT BONE HV CEMENT 20G,10269119,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1699.00,509.70,722.07,1444.15,,,,,,,,,,,,,service not payable,,,,,,,856.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,722.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1274.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,849.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1274.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1444.15,,,percent of total billed charges,,,781.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXTENSION TIBIA 10X132MM X_NX083Z X_AESCULAP,10269120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXTENSION TIBIA 10X132MM X_NX083Z X_AESCULAP,10269120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLODERM RTU PERF CON LG THICK,10269121,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,17555.00,5266.50,6811.34,14921.75,,8601.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7373.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6811.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7460.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13166.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8777.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14921.75,,,percent of total billed charges,,,7899.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLODERM RTU PERF CON LG THICK,10269121,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,17555.00,5266.50,7373.10,17555.0,,8601.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7373.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8854.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7460.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13166.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8777.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13166.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14921.75,,,percent of total billed charges,,,8075.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,17555.0,,,percent of total billed charges,,,,,,,,service not payable,17555.0,,,percent of total billed charges,,
ALLODERM RTU PERF CON LG THICK,10269121,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,17555.00,5266.50,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block/Sngl-SP,10269305,CDM,0490,RC,64445,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block/Sngl-SP,10269305,CDM,0490,RC,64445,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Sciatic Nerve Block/Sngl-SP,10269305,CDM,0490,RC,64445,CPT,214,EAPG,,,,outpatient,facility,,,2202.00,660.60,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Sciatic Nerve Block/Sngl-CT,10269307,CDM,0490,RC,64445,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block/Sngl-CT,10269307,CDM,0490,RC,64445,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Sciatic Nerve Block/Sngl-CT,10269307,CDM,0490,RC,64445,CPT,214,EAPG,,,,outpatient,facility,,,2202.00,660.60,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Sciatic Nerve Block/Sngl-SP,10269308,CDM,0490,RC,64445,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block/Sngl-SP,10269308,CDM,0490,RC,64445,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Sciatic Nerve Block/Sngl-SP,10269308,CDM,0490,RC,64445,CPT,214,EAPG,,,,outpatient,facility,,,2202.00,660.60,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Sciatic Nerve Block/Sngl-CT,10269309,CDM,0490,RC,64445,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Sciatic Nerve Block/Sngl-CT,10269309,CDM,0490,RC,64445,CPT,05442,APC,,,,outpatient,facility,,,2202.00,660.60,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Sciatic Nerve Block/Sngl-CT,10269309,CDM,0490,RC,64445,CPT,214,EAPG,,,,outpatient,facility,,,2202.00,660.60,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Inj Pudendal Nerve Block,10269328,CDM,0490,RC,64430,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Inj Pudendal Nerve Block,10269328,CDM,0490,RC,64430,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Inj Pudendal Nerve Block,10269328,CDM,0490,RC,64430,CPT,220,EAPG,,,,outpatient,facility,,,2202.00,660.60,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Inj Pudendal Nerve Block,10269329,CDM,0490,RC,64430,CPT,,,,,,outpatient,facility,,,2202.00,660.60,1012.92,2912.34,,2202.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1110.69,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Inj Pudendal Nerve Block,10269329,CDM,0490,RC,64430,CPT,05443,APC,,,,outpatient,facility,,,2202.00,660.60,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Inj Pudendal Nerve Block,10269329,CDM,0490,RC,64430,CPT,220,EAPG,,,,outpatient,facility,,,2202.00,660.60,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Gentamicin Trough,1027,CDM,0300,RC,80170,CPT,,,,,,outpatient,facility,,,196.00,58.80,15.56,166.60,,69.63,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.05,,,fee schedule,,,51.96,,,fee schedule,,,34.16,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,33.91,,,fee schedule,,,15.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.37,,,fee schedule,,,37.02,,,fee schedule,,,,,,,,,16.05,,,fee schedule,,,,,,,,,21.06,,,fee schedule,,,33.42,,,fee schedule,,,147.0,,,percent of total billed charges,,,16.05,,,fee schedule,,,15.56,,,fee schedule,,,16.37,,,fee schedule,,,24.77,,,fee schedule,,,16.05,,,fee schedule,,,147.0,,,percent of total billed charges,,,,,,,,,16.37,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,18.02,,,fee schedule,,,16.05,,,fee schedule,,,,,,,,,15.89,,,fee schedule,,,16.05,,,fee schedule,,,,,,,,,16.21,,,fee schedule,,,,,,,,
Gentamicin Trough,1027,CDM,0300,RC,80170,CPT,405,EAPG,,,,outpatient,facility,,,196.00,58.80,14.30,137.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,116.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,66.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LEAD KIT INFINION CX NHPL 70CM,10270727,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT INFINION CX NHPL 70CM,10270727,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUMB 9X23MMX6D X_48950096 X_STRYKER SPIN,10270728,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUMB 9X23MMX6D X_48950096 X_STRYKER SPIN,10270728,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLBL UNITE ANT BODY 128 SZ 10,10270729,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLBL UNITE ANT BODY 128 SZ 10,10270729,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT HUM SHOULDER 42X6X12.5,10270730,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4384.00,1315.20,1700.99,3726.40,,,,,,,,,,,,,,,,,,,,1700.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1863.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3726.40,,,percent of total billed charges,,,1972.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT HUM SHOULDER 42X6X12.5,10270730,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4384.00,1315.20,1863.2,3726.40,,,,,,,,,,,,,service not payable,,,,,,,2211.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1863.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3726.40,,,percent of total billed charges,,,2016.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE GLENOID 29MM 15DEG P,10270731,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11145.00,3343.50,4324.26,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9473.25,,,percent of total billed charges,,,5015.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE GLENOID 29MM 15DEG P,10270731,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11145.00,3343.50,4680.90,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5621.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9473.25,,,percent of total billed charges,,,5126.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ALPS HUM PROX 80MM 3H,10270732,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8163.00,2448.90,3167.24,6938.55,,3999.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3428.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3167.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3469.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4081.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6938.55,,,percent of total billed charges,,,3673.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ALPS HUM PROX 80MM 3H,10270732,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8163.00,2448.90,3428.46,6938.55,,3999.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3428.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4117.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3469.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4081.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6938.55,,,percent of total billed charges,,,3754.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING ALPS 3.5X36MM,10270733,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING ALPS 3.5X36MM,10270733,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING CANC 4X26MM,10270734,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING CANC 4X26MM,10270734,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING CANC 4X28MM,10270735,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING CANC 4X28MM,10270735,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING CANC 4X30MM,10270736,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING CANC 4X30MM,10270736,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING CANC 4X32MM,10270737,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING CANC 4X32MM,10270737,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING CANC 4X36MM,10270738,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING CANC 4X36MM,10270738,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING CANC 4X48MM,10270739,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING CANC 4X48MM,10270739,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATO POLYAX 5.5X45MM,10270740,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO POLYAX 5.5X45MM,10270740,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 6.5X55MM X_48261555 X_STRYKER,10270741,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 6.5X55MM X_48261555 X_STRYKER,10270741,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ECLIPSE COLLARLESS HIGH SZ 10,10270742,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ECLIPSE COLLARLESS HIGH SZ 10,10270742,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT DIS SIG SZ2.5 8MM RT,10270743,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT DIS SIG SZ2.5 8MM RT,10270743,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 6.5X65MM X_71106265S X_SMITH NEPHEW,10270744,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 6.5X65MM X_71106265S X_SMITH NEPHEW,10270744,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STND WALL 6MMX20CM,10270745,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1733.00,519.90,672.40,1473.05,,,,,,,,,,,,,,,,,,,,672.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,736.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1299.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,866.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1473.05,,,percent of total billed charges,,,779.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STND WALL 6MMX20CM,10270745,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1733.00,519.90,736.52,1473.05,,,,,,,,,,,,,service not payable,,,,,,,874.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,736.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1299.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,866.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1299.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1473.05,,,percent of total billed charges,,,797.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U4 2X15X150,10270746,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE POS FEM AUG SZ 7 12MM,10270747,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE POS FEM AUG SZ 7 12MM,10270747,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CERVICAL COLLAR ASPEN ADULT SHORT X_ASPE-983128 X_,10272260,CDM,0274,RC,L0120,HCPCS,,,,,,inpatient,facility,,,174.00,52.20,67.51,147.90,,,,,,,,,,,,,,,,,,,,67.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,130.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.90,,,percent of total billed charges,,,78.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CERVICAL COLLAR ASPEN ADULT SHORT X_ASPE-983128 X_,10272260,CDM,0274,RC,L0120,HCPCS,,,,,,outpatient,facility,,,174.00,52.20,27.36,147.90,,,,,,,,39.23,,,fee schedule,,,,,,,,,87.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,82.53,,,fee schedule,,,27.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",40.01,,,fee schedule,,,90.11,,,fee schedule,,,,,,,,,39.23,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,Paid in addition to outpatient services ,81.33,,,fee schedule,,,130.5,,,percent of total billed charges,,,39.23,,,fee schedule,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,87.0,,,percent of total billed charges,,Paid in addition to outpatient services ,39.23,,,fee schedule,,,130.5,,,percent of total billed charges,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,,,,,,,147.90,,,percent of total billed charges,,,80.04,,,percent of total billed charges,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,39.63,,,fee schedule,,,,,,,,
CERVICAL COLLAR ASPEN ADULT REG X_ASPE-983130 X_33,10272261,CDM,0274,RC,L0120,HCPCS,,,,,,inpatient,facility,,,174.00,52.20,67.51,147.90,,,,,,,,,,,,,,,,,,,,67.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,130.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.90,,,percent of total billed charges,,,78.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CERVICAL COLLAR ASPEN ADULT REG X_ASPE-983130 X_33,10272261,CDM,0274,RC,L0120,HCPCS,,,,,,outpatient,facility,,,174.00,52.20,27.36,147.90,,,,,,,,39.23,,,fee schedule,,,,,,,,,87.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,82.53,,,fee schedule,,,27.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",40.01,,,fee schedule,,,90.11,,,fee schedule,,,,,,,,,39.23,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,Paid in addition to outpatient services ,81.33,,,fee schedule,,,130.5,,,percent of total billed charges,,,39.23,,,fee schedule,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,87.0,,,percent of total billed charges,,Paid in addition to outpatient services ,39.23,,,fee schedule,,,130.5,,,percent of total billed charges,,,27.36,,,fee schedule,,,40.01,,,fee schedule,,,,,,,,,147.90,,,percent of total billed charges,,,80.04,,,percent of total billed charges,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,,,,,,,39.23,,,fee schedule,,,,,,,,,39.63,,,fee schedule,,,,,,,,
GC Screen,10273,CDM,0300,RC,87081,CPT,,,,,,outpatient,facility,,,79.00,23.70,6.30,67.15,,28.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.5,,,fee schedule,,,21.02,,,fee schedule,,,13.82,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.72,,,fee schedule,,,6.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.63,,,fee schedule,,,14.98,,,fee schedule,,,,,,,,,6.5,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.53,,,fee schedule,,,59.25,,,percent of total billed charges,,,6.5,,,fee schedule,,,6.30,,,fee schedule,,,6.63,,,fee schedule,,,9.92,,,fee schedule,,,6.5,,,fee schedule,,,59.25,,,percent of total billed charges,,,,,,,,,6.63,,,fee schedule,,,,,,,,,67.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,,,,,,,7.29,,,fee schedule,,,6.5,,,fee schedule,,,,,,,,,6.43,,,fee schedule,,,6.5,,,fee schedule,,,,,,,,,6.57,,,fee schedule,,,,,,,,
GC Screen,10273,CDM,0300,RC,87081,CPT,396,EAPG,,,,outpatient,facility,,,79.00,23.70,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MRSA Screen,10274,CDM,0300,RC,87081,CPT,,,,,,outpatient,facility,,,80.00,24.00,6.30,68.0,,28.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.5,,,fee schedule,,,21.02,,,fee schedule,,,13.82,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.72,,,fee schedule,,,6.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.63,,,fee schedule,,,14.98,,,fee schedule,,,,,,,,,6.5,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.53,,,fee schedule,,,60.0,,,percent of total billed charges,,,6.5,,,fee schedule,,,6.30,,,fee schedule,,,6.63,,,fee schedule,,,9.92,,,fee schedule,,,6.5,,,fee schedule,,,60.0,,,percent of total billed charges,,,,,,,,,6.63,,,fee schedule,,,,,,,,,68.0,,,percent of total billed charges,,,36.80,,,percent of total billed charges,,,,,,,,,7.29,,,fee schedule,,,6.5,,,fee schedule,,,,,,,,,6.43,,,fee schedule,,,6.5,,,fee schedule,,,,,,,,,6.57,,,fee schedule,,,,,,,,
MRSA Screen,10274,CDM,0300,RC,87081,CPT,396,EAPG,,,,outpatient,facility,,,80.00,24.00,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT ENDURANT II BF MAIN BODY 28X16MM X_ETBF2816C,10274953,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,29430.00,8829.00,11418.84,25015.5,,14420.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12360.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11418.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12507.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22072.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14715.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25015.5,,,percent of total billed charges,,,13243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ENDURANT II BF MAIN BODY 28X16MM X_ETBF2816C,10274953,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,29430.00,8829.00,12360.6,25015.5,,14420.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12360.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14844.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12507.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14715.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22072.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,25015.5,,,percent of total billed charges,,,13537.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AVIATOR 24MM X_48811224 X_STRYKER,10274954,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AVIATOR 24MM X_48811224 X_STRYKER,10274954,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO DBM W/CANCELLOUS S.,10274955,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3231.00,969.30,1253.63,2746.35,,,,,,,,,,,,,,,,,,,,1253.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1373.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2423.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2746.35,,,percent of total billed charges,,,1453.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY BIO DBM W/CANCELLOUS S.,10274955,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3231.00,969.30,1373.18,2746.35,,,,,,,,,,,,,service not payable,,,,,,,1629.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1373.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2423.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2423.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2746.35,,,percent of total billed charges,,,1486.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT BIO CANC 5CCX1-8MM,10274956,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,347.00,104.10,134.64,294.95,,,,,,,,,,,,,,,,,,,,134.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,260.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.95,,,percent of total billed charges,,,156.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT BIO CANC 5CCX1-8MM,10274956,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,347.00,104.10,147.47,294.95,,,,,,,,,,,,,service not payable,,,,,,,175.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,147.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,260.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,173.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,260.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,294.95,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT BIO CANC 5CCX1-8MM,10274956,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,347.00,104.10,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH DRAIN THAL-QUICK 16F 41CM,10274957,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,649.00,194.70,275.82,551.65,,401.08,,,percent of total billed charges,,,,,,,,service not payable,316.71,,,percent of total billed charges,,,327.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,275.82,,,percent of total billed charges,,,,,,,,,486.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,324.5,,,percent of total billed charges,,,,,,,,service not payable,486.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,551.65,,,percent of total billed charges,,,298.54,,,percent of total billed charges,,,,,,,,,421.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,421.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SEEKER 0.035X90,10274958,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR ICD VISIA VR D4 MRI X_DVFB1D4 X_MEDTRONI,10274959,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,23310.00,6993.00,9044.28,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9790.20,,,percent of total billed charges,,Paid in addition to inpatient services ,9044.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19813.5,,,percent of total billed charges,,,10489.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR ICD VISIA VR D4 MRI X_DVFB1D4 X_MEDTRONI,10274959,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,23310.00,6993.00,9790.20,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9790.20,,,percent of total billed charges,,Paid in addition to outpatient services ,11757.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19813.5,,,percent of total billed charges,,,10722.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X54MM,1027517,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,105.00,31.50,40.74,89.25,,,,,,,,,,,,,,,,,,,,40.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,78.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,47.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X54MM,1027517,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,105.00,31.50,44.62,89.25,,,,,,,,,,,,,service not payable,,,,,,,52.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,44.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,78.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,52.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,78.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,89.25,,,percent of total billed charges,,,48.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X56MM,1027518,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,106.00,31.80,41.13,90.10,,,,,,,,,,,,,,,,,,,,41.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.10,,,percent of total billed charges,,,47.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X56MM,1027518,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,106.00,31.80,45.05,90.10,,,,,,,,,,,,,service not payable,,,,,,,53.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,45.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,79.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,53.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,79.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,90.10,,,percent of total billed charges,,,48.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X52MM,1027519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,105.00,31.50,40.74,89.25,,,,,,,,,,,,,,,,,,,,40.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,78.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,47.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X52MM,1027519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,105.00,31.50,44.62,89.25,,,,,,,,,,,,,service not payable,,,,,,,52.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,44.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,78.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,52.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,78.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,89.25,,,percent of total billed charges,,,48.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X50MM,1027520,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,105.00,31.50,40.74,89.25,,,,,,,,,,,,,,,,,,,,40.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,78.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,47.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X50MM,1027520,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,105.00,31.50,44.62,89.25,,,,,,,,,,,,,service not payable,,,,,,,52.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,44.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,78.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,52.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,78.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,89.25,,,percent of total billed charges,,,48.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X46MM,1027521,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,131.00,39.30,50.83,111.35,,,,,,,,,,,,,,,,,,,,50.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,98.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.35,,,percent of total billed charges,,,58.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X46MM,1027521,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,131.00,39.30,55.67,111.35,,,,,,,,,,,,,service not payable,,,,,,,66.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,55.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,98.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,65.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,98.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,111.35,,,percent of total billed charges,,,60.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X44MM,1027522,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,137.00,41.10,53.16,116.45,,,,,,,,,,,,,,,,,,,,53.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,61.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X44MM,1027522,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,137.00,41.10,58.23,116.45,,,,,,,,,,,,,service not payable,,,,,,,69.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,102.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X42MM,1027523,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,136.00,40.80,52.77,115.60,,,,,,,,,,,,,,,,,,,,52.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,102.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.60,,,percent of total billed charges,,,61.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X42MM,1027523,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,136.00,40.80,57.80,115.60,,,,,,,,,,,,,service not payable,,,,,,,68.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,57.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,102.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,68.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,102.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,115.60,,,percent of total billed charges,,,62.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X48MM,1027530,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,111.00,33.30,43.07,94.35,,,,,,,,,,,,,,,,,,,,43.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,83.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.35,,,percent of total billed charges,,,49.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X48MM,1027530,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,111.00,33.30,47.17,94.35,,,,,,,,,,,,,service not payable,,,,,,,55.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,47.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,83.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,55.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,83.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,94.35,,,percent of total billed charges,,,51.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SURGISIS ANAL FIST PLUG,1027532,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4177.00,1253.10,1620.68,3550.45,,,,,,,,,,,,,,,,,,,,1620.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1775.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3132.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2088.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3550.45,,,percent of total billed charges,,,1879.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SURGISIS ANAL FIST PLUG,1027532,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4177.00,1253.10,1775.22,3550.45,,,,,,,,,,,,,service not payable,,,,,,,2106.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1775.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3132.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2088.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3132.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3550.45,,,percent of total billed charges,,,1921.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL BONE 4.5X58MM,1027534,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,106.00,31.80,41.13,90.10,,,,,,,,,,,,,,,,,,,,41.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.10,,,percent of total billed charges,,,47.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL BONE 4.5X58MM,1027534,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,106.00,31.80,45.05,90.10,,,,,,,,,,,,,service not payable,,,,,,,53.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,45.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,79.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,53.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,79.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,90.10,,,percent of total billed charges,,,48.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 3.5X22MM X_71149522 X_RICHARDS MFG CO,1027539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,158.00,47.40,61.30,134.30,,,,,,,,,,,,,,,,,,,,61.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,118.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.30,,,percent of total billed charges,,,71.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 3.5X22MM X_71149522 X_RICHARDS MFG CO,1027539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,158.00,47.40,67.15,134.30,,,,,,,,,,,,,service not payable,,,,,,,79.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,67.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,118.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,79.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,118.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,134.30,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.4X32MM X_71661232 X_RICHARDS MFG CO,1027540,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1017.00,305.10,394.60,864.45,,,,,,,,,,,,,,,,,,,,394.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.45,,,percent of total billed charges,,,457.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.4X32MM X_71661232 X_RICHARDS MFG CO,1027540,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.22,864.45,,,,,,,,,,,,,service not payable,,,,,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 12/14 36MM X_71343608 X_RICHARDS MFG,1027541,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 12/14 36MM X_71343608 X_RICHARDS MFG,1027541,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP JET 4MM X_71062011 X_RICHARDS MFG CO,1027542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2126.00,637.80,824.89,1807.10,,,,,,,,,,,,,,,,,,,,824.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1594.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1063.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1807.10,,,percent of total billed charges,,,956.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP JET 4MM X_71062011 X_RICHARDS MFG CO,1027542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2126.00,637.80,903.55,1807.10,,,,,,,,,,,,,service not payable,,,,,,,1072.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,903.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1594.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1063.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1594.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1807.10,,,percent of total billed charges,,,977.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 9/7.5MM 24CM,1027544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5338.00,1601.40,2071.14,4537.30,,2615.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2241.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2071.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2268.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4003.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2669.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4537.30,,,percent of total billed charges,,,2402.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 9/7.5MM 24CM,1027544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5338.00,1601.40,2241.96,4537.30,,2615.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2241.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2692.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2268.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4003.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2669.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4003.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4537.30,,,percent of total billed charges,,,2455.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL SM RMP 300ML,1027545,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4175.00,1252.50,1619.90,3548.75,,,,,,,,,,,,,,,,,,,,1619.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1774.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3131.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2087.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3548.75,,,percent of total billed charges,,,1878.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL SM RMP 300ML,1027545,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4175.00,1252.50,1774.38,3548.75,,,,,,,,,,,,,service not payable,,,,,,,2105.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1774.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3131.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2087.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3131.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3548.75,,,percent of total billed charges,,,1920.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BREAST X_15-575 X_ALLERGAN INC,1027546,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BREAST X_15-575 X_ALLERGAN INC,1027546,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD 52CM X_1788T-52 X_ST JUDE,1027547,CDM,0275,RC,C1898,HCPCS,,,,,,inpatient,facility,,,3467.00,1040.10,1345.20,2946.95,,,,,,,,,,,,,,,,,,,,1345.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1473.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2600.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1733.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2946.95,,,percent of total billed charges,,,1560.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD 52CM X_1788T-52 X_ST JUDE,1027547,CDM,0275,RC,C1898,HCPCS,,,,,,outpatient,facility,,,3467.00,1040.10,1473.47,2946.95,,,,,,,,,,,,,service not payable,,,,,,,1748.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1473.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2600.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1733.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2600.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2946.95,,,percent of total billed charges,,,1594.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER PALI 14.5FX28 X_8888145011 X_KENDALL,1027560,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,2029.00,608.70,862.33,1724.65,,1253.92,,,percent of total billed charges,,,,,,,,service not payable,990.15,,,percent of total billed charges,,,1023.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,862.33,,,percent of total billed charges,,,,,,,,,1521.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.5,,,percent of total billed charges,,,,,,,,service not payable,1521.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1724.65,,,percent of total billed charges,,,933.34,,,percent of total billed charges,,,,,,,,,1318.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1318.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER PALI 14.5FX33 X_8888145061 X_KENDALL,1027561,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,2029.00,608.70,862.33,1724.65,,1253.92,,,percent of total billed charges,,,,,,,,service not payable,990.15,,,percent of total billed charges,,,1023.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,862.33,,,percent of total billed charges,,,,,,,,,1521.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.5,,,percent of total billed charges,,,,,,,,service not payable,1521.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1724.65,,,percent of total billed charges,,,933.34,,,percent of total billed charges,,,,,,,,,1318.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1318.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER PALI 14.5FX23 X_8888145059 X_KENDALL,1027562,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,2223.00,666.90,944.77,1889.55,,1373.81,,,percent of total billed charges,,,,,,,,service not payable,1084.82,,,percent of total billed charges,,,1121.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,944.77,,,percent of total billed charges,,,,,,,,,1667.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,service not payable,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1889.55,,,percent of total billed charges,,,1022.58,,,percent of total billed charges,,,,,,,,,1444.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1444.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE ALLODERM 4X7,1027567,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,4257.00,1277.10,1651.72,3618.45,,,,,,,,,,,,,,,,,,,,1651.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1809.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3192.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2128.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3618.45,,,percent of total billed charges,,,1915.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE ALLODERM 4X7,1027567,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,4257.00,1277.10,1809.22,4257.0,,,,,,,,,,,,,service not payable,,,,,,,2147.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1809.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3192.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2128.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3192.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3618.45,,,percent of total billed charges,,,1958.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,4257.0,,,percent of total billed charges,,,,,,,,service not payable,4257.0,,,percent of total billed charges,,
TISSUE ALLODERM 4X7,1027567,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,4257.00,1277.10,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 6.5X60MM X_016560 X_CUSTOM SPINE,1027568,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3775.00,1132.50,1464.7,3208.75,,,,,,,,,,,,,,,,,,,,1464.7,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1887.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3208.75,,,percent of total billed charges,,,1698.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 6.5X60MM X_016560 X_CUSTOM SPINE,1027568,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3775.00,1132.50,1604.38,3208.75,,,,,,,,,,,,,service not payable,,,,,,,1904.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1604.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2831.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1887.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2831.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3208.75,,,percent of total billed charges,,,1736.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM REST MOD CON 17X155,1027570,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9276.00,2782.80,3599.09,7884.60,,4545.24,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3895.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3599.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3942.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6957.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4638.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7884.60,,,percent of total billed charges,,,4174.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REST MOD CON 17X155,1027570,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9276.00,2782.80,3895.92,7884.60,,4545.24,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3895.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4678.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3942.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6957.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4638.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6957.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7884.60,,,percent of total billed charges,,,4266.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TENODESIS 5.5X15MM X_AR-1555B X_ARTHREX I,1027574,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1233.00,369.90,478.40,1048.05,,,,,,,,,,,,,,,,,,,,478.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,924.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1048.05,,,percent of total billed charges,,,554.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TENODESIS 5.5X15MM X_AR-1555B X_ARTHREX I,1027574,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1233.00,369.90,524.02,1048.05,,,,,,,,,,,,,service not payable,,,,,,,621.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,524.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,924.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,616.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,924.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1048.05,,,percent of total billed charges,,,567.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Pinworm Screen,10276,CDM,0300,RC,87172,CPT,,,,,,outpatient,facility,,,32.00,9.60,4.06,27.20,,18.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.18,,,fee schedule,,,13.54,,,fee schedule,,,8.90,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,8.84,,,fee schedule,,,4.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.26,,,fee schedule,,,9.65,,,fee schedule,,,,,,,,,4.18,,,fee schedule,,,,,,,,,5.47,,,fee schedule,,,8.71,,,fee schedule,,,24.0,,,percent of total billed charges,,,4.18,,,fee schedule,,,4.06,,,fee schedule,,,4.26,,,fee schedule,,,6.44,,,fee schedule,,,4.18,,,fee schedule,,,24.0,,,percent of total billed charges,,,,,,,,,4.26,,,fee schedule,,,,,,,,,27.20,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,4.70,,,fee schedule,,,4.18,,,fee schedule,,,,,,,,,4.14,,,fee schedule,,,4.18,,,fee schedule,,,,,,,,,4.22,,,fee schedule,,,,,,,,
Pinworm Screen,10276,CDM,0300,RC,87172,CPT,396,EAPG,,,,outpatient,facility,,,32.00,9.60,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Circumcision Procedure - Circumcision Charge,1027616,CDM,0723,RC,54160,CPT,,,,,,outpatient,facility,,,967.00,290.10,410.98,821.95,,597.61,,,percent of total billed charges,,,,,,,,,471.90,,,percent of total billed charges,,,487.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.98,,,percent of total billed charges,,,,,,,,,725.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,483.5,,,percent of total billed charges,,,,,,,,,725.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,821.95,,,percent of total billed charges,,,444.82,,,percent of total billed charges,,,,,,,,,628.55,,,percent of total billed charges,,,,,,,,,,,,,,,628.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
Circumcision Procedure - Circumcision Charge,1027616,CDM,0723,RC,54160,CPT,05372,APC,,,,outpatient,facility,,,967.00,290.10,613.95,1470.11,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1346.51,,,fee schedule,,,613.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",652.88,,,fee schedule,,,1470.11,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1327.00,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,613.95,,,fee schedule,,,652.88,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,613.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",652.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,646.45,,,fee schedule,,,,,,,,
Circumcision Procedure - Circumcision Charge,1027616,CDM,0723,RC,54160,CPT,183,EAPG,,,,outpatient,facility,,,967.00,290.10,967.0,8205.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8205.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6974.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,967.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,967.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,967.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2742.88,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3017.17,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Circumcision Procedure - Circumcision Charge,1027616,CDM,0723,RC,54150,CPT,,,,,,outpatient,facility,,,967.00,290.10,410.98,821.95,,597.61,,,percent of total billed charges,,,,,,,,,471.90,,,percent of total billed charges,,,487.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.98,,,percent of total billed charges,,,,,,,,,725.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,483.5,,,percent of total billed charges,,,,,,,,,725.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,821.95,,,percent of total billed charges,,,444.82,,,percent of total billed charges,,,,,,,,,628.55,,,percent of total billed charges,,,,,,,,,,,,,,,628.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
Circumcision Procedure - Circumcision Charge,1027616,CDM,0723,RC,54150,CPT,05373,APC,,,,outpatient,facility,,,967.00,290.10,967.0,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,967.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,967.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
Circumcision Procedure - Circumcision Charge,1027616,CDM,0723,RC,54150,CPT,183,EAPG,,,,outpatient,facility,,,967.00,290.10,967.0,8205.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8205.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6974.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,967.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,967.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,967.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2742.88,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3017.17,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Candida Screen,10277,CDM,0300,RC,87081,CPT,,,,,,outpatient,facility,,,44.00,13.20,6.30,37.40,,28.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.5,,,fee schedule,,,21.02,,,fee schedule,,,13.82,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.72,,,fee schedule,,,6.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.63,,,fee schedule,,,14.98,,,fee schedule,,,,,,,,,6.5,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.53,,,fee schedule,,,33.0,,,percent of total billed charges,,,6.5,,,fee schedule,,,6.30,,,fee schedule,,,6.63,,,fee schedule,,,9.92,,,fee schedule,,,6.5,,,fee schedule,,,33.0,,,percent of total billed charges,,,,,,,,,6.63,,,fee schedule,,,,,,,,,37.40,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,7.29,,,fee schedule,,,6.5,,,fee schedule,,,,,,,,,6.43,,,fee schedule,,,6.5,,,fee schedule,,,,,,,,,6.57,,,fee schedule,,,,,,,,
Candida Screen,10277,CDM,0300,RC,87081,CPT,396,EAPG,,,,outpatient,facility,,,44.00,13.20,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TIBIAL AUG HLF BLK 3 5MM X_5545-A-302 X_STRYKER OR,10278002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3397.00,1019.10,1318.04,2887.45,,,,,,,,,,,,,,,,,,,,1318.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1443.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1698.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2887.45,,,percent of total billed charges,,,1528.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUG HLF BLK 3 5MM X_5545-A-302 X_STRYKER OR,10278002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3397.00,1019.10,1443.72,2887.45,,,,,,,,,,,,,service not payable,,,,,,,1713.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1443.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2547.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1698.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2887.45,,,percent of total billed charges,,,1562.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT TIB SYM SZ A,10278003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13148.00,3944.40,5101.42,11175.80,,6442.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5522.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5101.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5587.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11175.80,,,percent of total billed charges,,,5916.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT TIB SYM SZ A,10278003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13148.00,3944.40,5522.16,11175.80,,6442.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5522.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6631.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5587.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11175.80,,,percent of total billed charges,,,6048.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SONICWELD SONICPIN RXG 2.1X4MM,10278004,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7606.00,2281.80,2951.13,6465.10,,3726.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3194.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2951.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3232.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5704.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3803.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6465.10,,,percent of total billed charges,,,3422.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SONICWELD SONICPIN RXG 2.1X4MM,10278004,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7606.00,2281.80,3194.52,6465.10,,3726.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3194.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3836.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3232.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5704.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3803.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5704.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6465.10,,,percent of total billed charges,,,3498.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER 6X14X11MM X_7270641 X_MEDTRONIC,10278006,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER 6X14X11MM X_7270641 X_MEDTRONIC,10278006,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 4.0X34MM X_873-134 X_MEDTRONIC,10278007,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3944.00,1183.20,1530.27,3352.40,,,,,,,,,,,,,,,,,,,,1530.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1676.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2958.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1972.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.40,,,percent of total billed charges,,,1774.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 4.0X34MM X_873-134 X_MEDTRONIC,10278007,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3944.00,1183.20,1676.2,3352.40,,,,,,,,,,,,,service not payable,,,,,,,1989.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1676.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2958.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1972.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2958.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3352.40,,,percent of total billed charges,,,1814.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM RADIAL HEAD 9X6MM X_TR-S0906-S X_ACUMED,10278358,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5364.00,1609.20,2081.23,4559.40,,2628.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2252.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2081.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2279.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4023.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4559.40,,,percent of total billed charges,,,2413.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM RADIAL HEAD 9X6MM X_TR-S0906-S X_ACUMED,10278358,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5364.00,1609.20,2252.88,4559.40,,2628.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2252.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2705.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2279.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4023.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4023.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4559.40,,,percent of total billed charges,,,2467.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE PEEK AVS 6X12X14MM 4D,10278360,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PEEK AVS 6X12X14MM 4D,10278360,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CERV AVS SD 3.5X10MM,10278361,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CERV AVS SD 3.5X10MM,10278361,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SELF-DRILL ANCHOR 3.5X14MM X_48335314 X_STRY,10278362,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SELF-DRILL ANCHOR 3.5X14MM X_48335314 X_STRY,10278362,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Reconstituted Red Cells Pool Fee,102872,CDM,0300,RC,86965,CPT,,,,,,outpatient,facility,,,26.00,7.80,11.96,179.01,,16.07,,,percent of total billed charges,,,,,,,,,12.79,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.59,,,fee schedule,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.56,,,fee schedule,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.10,,,percent of total billed charges,,,11.96,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Reconstituted Red Cells Pool Fee,102872,CDM,0300,RC,86965,CPT,05672,APC,,,,outpatient,facility,,,26.00,7.80,26.0,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,26.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,26.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Reconstituted Red Cells Pool Fee,102872,CDM,0300,RC,86965,CPT,499,EAPG,,,,outpatient,facility,,,26.00,7.80,26.0,240.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,204.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,161.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,178.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Directed Reconstituted Red Cells Pool Fee,102876,CDM,0300,RC,86965,CPT,,,,,,outpatient,facility,,,26.00,7.80,11.96,179.01,,16.07,,,percent of total billed charges,,,,,,,,,12.79,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.59,,,fee schedule,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.56,,,fee schedule,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.10,,,percent of total billed charges,,,11.96,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Directed Reconstituted Red Cells Pool Fee,102876,CDM,0300,RC,86965,CPT,05672,APC,,,,outpatient,facility,,,26.00,7.80,26.0,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,26.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,26.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Directed Reconstituted Red Cells Pool Fee,102876,CDM,0300,RC,86965,CPT,499,EAPG,,,,outpatient,facility,,,26.00,7.80,26.0,240.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,204.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,161.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,178.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SLING OBTRYX II HALO,10292185,CDM,0278,RC,C1771,HCPCS,,,,,,inpatient,facility,,,4039.00,1211.70,1567.13,3433.15,,,,,,,,,,,,,,,,,,,,1567.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1716.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2019.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3433.15,,,percent of total billed charges,,,1817.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLING OBTRYX II HALO,10292185,CDM,0278,RC,C1771,HCPCS,,,,,,outpatient,facility,,,4039.00,1211.70,1716.58,3433.15,,,,,,,,,,,,,service not payable,,,,,,,2037.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1716.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3029.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2019.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3433.15,,,percent of total billed charges,,,1857.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FT 2.4X24MM X_656124 X_STRYKER ORTHOPAE,10292186,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FT 2.4X24MM X_656124 X_STRYKER ORTHOPAE,10292186,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.4 X 18MM,10292187,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.4 X 18MM,10292187,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG FLAT LRG TI X_I00100 X_INTEGRATED ORBITAL INC,10292190,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG FLAT LRG TI X_I00100 X_INTEGRATED ORBITAL INC,10292190,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM REDAPT SZ19 240MM X_71354708 X_SMITH NEPHEW,10292191,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24792.00,7437.60,9619.30,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9619.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21073.20,,,percent of total billed charges,,,11156.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REDAPT SZ19 240MM X_71354708 X_SMITH NEPHEW,10292191,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24792.00,7437.60,10412.64,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12505.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21073.20,,,percent of total billed charges,,,11404.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIBRILLATOR 0.99X5.37X8.18CM,10292195,CDM,0278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,28057.00,8417.10,10886.12,23848.45,,13747.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11783.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10886.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11924.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21042.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14028.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23848.45,,,percent of total billed charges,,,12625.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIBRILLATOR 0.99X5.37X8.18CM,10292195,CDM,0278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,28057.00,8417.10,11783.94,23848.45,,13747.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11783.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14151.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11924.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21042.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14028.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21042.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,23848.45,,,percent of total billed charges,,,12906.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SEALANT TRACT BIOSENTRY,10292196,CDM,0272,RC,C2613,HCPCS,,,,,,outpatient,facility,,,1722.00,516.60,731.85,1463.7,,1064.2,,,percent of total billed charges,,,,,,,,service not payable,840.34,,,percent of total billed charges,,,868.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,,,,,,,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1463.7,,,percent of total billed charges,,,792.12,,,percent of total billed charges,,,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Blood Collection/Venipuncture,10292410,CDM,0450,RC,36415,CPT,,,,,,outpatient,facility,,,28.00,8.40,4.32,880.0,,17.30,,,percent of total billed charges,,,8.91,,,fee schedule,,,13.66,,,percent of total billed charges,,,14.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,18.82,,,fee schedule,,,4.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",9.09,,,fee schedule,,,20.54,,,fee schedule,,,,,,,,,8.91,,,fee schedule,,,,,,,,,,,,,,service not payable,18.54,,,fee schedule,,,21.0,,,percent of total billed charges,,,8.91,,,fee schedule,,,4.32,,,fee schedule,,,9.09,,,fee schedule,,,,,,,,service not payable,8.91,,,fee schedule,,,21.0,,,percent of total billed charges,,,,,,,,service not payable,9.09,,,fee schedule,,,,,,,,,23.80,,,percent of total billed charges,,,12.88,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,8.91,,,fee schedule,,,,,,,,,774.0,,,case rate,,,8.91,,,fee schedule,,,,,,,,,9.0,,,fee schedule,,,,,,,,
Blood Collection/Venipuncture,10292410,CDM,0450,RC,36415,CPT,304,EAPG,,,,outpatient,facility,,,28.00,8.40,3.89,12.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,10.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,9.30,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,10.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LINER ACET G7 NEUT 36MM,10292509,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14957.00,4487.10,5803.32,12713.45,,7328.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6281.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5803.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6356.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11217.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7478.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12713.45,,,percent of total billed charges,,,6730.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET G7 NEUT 36MM,10292509,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14957.00,4487.10,6281.94,12713.45,,7328.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6281.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7544.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6356.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11217.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7478.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11217.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12713.45,,,percent of total billed charges,,,6880.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE G7 LPR DOME 6.5X30,10292510,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,165.00,49.50,64.02,140.25,,,,,,,,,,,,,,,,,,,,64.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE G7 LPR DOME 6.5X30,10292510,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.12,140.25,,,,,,,,,,,,,service not payable,,,,,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 MULTI 60MM,10292511,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17431.00,5229.30,6763.23,14816.35,,8541.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7321.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6763.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7408.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13073.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8715.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14816.35,,,percent of total billed charges,,,7843.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 MULTI 60MM,10292511,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17431.00,5229.30,7321.02,14816.35,,8541.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7321.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8792.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7408.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13073.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8715.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13073.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14816.35,,,percent of total billed charges,,,8018.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12-14 TAPER 36MM,10292512,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6751.00,2025.30,2619.39,5738.35,,3307.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2835.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2619.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2869.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5063.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3375.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5738.35,,,percent of total billed charges,,,3037.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12-14 TAPER 36MM,10292512,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6751.00,2025.30,2835.42,5738.35,,3307.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2835.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3405.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2869.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5063.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3375.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5063.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5738.35,,,percent of total billed charges,,,3105.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 850CC,10292514,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 850CC,10292514,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 850CC UH,10292515,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 850CC UH,10292515,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW INTERFACE 8X30MM X_AR-4030C-08 X_ARTHREX INC,10292516,CDM,0277,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,996.22,,,percent of total billed charges,,,,,,,,service not payable,786.66,,,percent of total billed charges,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT EXCLUDER 26X14.5MM,10292517,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,25257.00,7577.10,9799.72,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9799.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21468.45,,,percent of total billed charges,,,11365.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT EXCLUDER 26X14.5MM,10292517,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,25257.00,7577.10,10607.94,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12739.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21468.45,,,percent of total billed charges,,,11618.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT EXCL C3 26X14.5MM,10292518,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,25257.00,7577.10,9799.72,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9799.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21468.45,,,percent of total billed charges,,,11365.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT EXCL C3 26X14.5MM,10292518,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,25257.00,7577.10,10607.94,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12739.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21468.45,,,percent of total billed charges,,,11618.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT EXCLUD 14CMX14.5MM,10292519,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15536.00,4660.80,6027.97,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6027.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13205.6,,,percent of total billed charges,,,6991.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT EXCLUD 14CMX14.5MM,10292519,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15536.00,4660.80,6525.12,13205.6,,7612.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6525.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7836.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6602.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11652.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11652.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13205.6,,,percent of total billed charges,,,7146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE POSITIONING COMP 6MM,10292520,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE POSITIONING COMP 6MM,10292520,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL COMP 6X122MM,10292521,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL COMP 6X122MM,10292521,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG BONE INTRAMEDULLARY SM 12,10292522,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG BONE INTRAMEDULLARY SM 12,10292522,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DESTINATION 6FR 65CM,10292523,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,362.15,,,percent of total billed charges,,,,,,,,service not payable,285.97,,,percent of total billed charges,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,380.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,380.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PACING TENDRIL MRI 52CM,10293051,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACING TENDRIL MRI 52CM,10293051,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PACING TENDRIL MRI 58CM,10293052,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACING TENDRIL MRI 58CM,10293052,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 4X6CM X_AAS-5460 X_MIMEDX,10293053,CDM,0278,RC,Q4100,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 4X6CM X_AAS-5460 X_MIMEDX,10293053,CDM,0278,RC,Q4100,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5901.0,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,5901.0,,,percent of total billed charges,,
GRAFT TISSUE ALLOGRAFT 4X6CM X_AAS-5460 X_MIMEDX,10293053,CDM,0278,RC,Q4100,HCPCS,455,EAPG,,,,outpatient,facility,,,5901.00,1770.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATHETER CXI SUPPORT X_G52545 X_COOK MEDICAL INC,10293055,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,888.00,266.40,377.40,754.80,,548.78,,,percent of total billed charges,,,,,,,,service not payable,433.34,,,percent of total billed charges,,,447.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,377.40,,,percent of total billed charges,,,,,,,,,666.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,444.0,,,percent of total billed charges,,,,,,,,service not payable,666.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,,408.48,,,percent of total billed charges,,,,,,,,,577.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,577.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE HI-TORQUE 10CM 4G 300XM X_1013731 X_ABBO,10293296,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,781.00,234.30,331.93,663.85,,482.66,,,percent of total billed charges,,,,,,,,service not payable,381.13,,,percent of total billed charges,,,393.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,331.93,,,percent of total billed charges,,,,,,,,,585.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,390.5,,,percent of total billed charges,,,,,,,,service not payable,585.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,663.85,,,percent of total billed charges,,,359.26,,,percent of total billed charges,,,,,,,,,507.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,507.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE HI-TORQUE 0.014IN 300CM,10293297,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,781.00,234.30,331.93,663.85,,482.66,,,percent of total billed charges,,,,,,,,service not payable,381.13,,,percent of total billed charges,,,393.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,331.93,,,percent of total billed charges,,,,,,,,,585.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,390.5,,,percent of total billed charges,,,,,,,,service not payable,585.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,663.85,,,percent of total billed charges,,,359.26,,,percent of total billed charges,,,,,,,,,507.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,507.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR TECNIS 31.0,10293804,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR TECNIS 31.0,10293804,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ARCHON LVL 2 40MM,10293805,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ARCHON LVL 2 40MM,10293805,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ARCHON VARI 15MM X_8780615 X_NUVASIVE,10293806,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ARCHON VARI 15MM X_8780615 X_NUVASIVE,10293806,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ARCHON FIXED 15MM X_8780915 X_NUVASIVE,10293807,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ARCHON FIXED 15MM X_8780915 X_NUVASIVE,10293807,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATO POLYAX 6.5X55MM,10293808,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO POLYAX 6.5X55MM,10293808,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PACING TENDRIL MRI 46CM,10293809,CDM,0278,RC,C1898,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACING TENDRIL MRI 46CM,10293809,CDM,0278,RC,C1898,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER THK6 50MM 47MM MRI,10293811,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,8753.00,2625.90,3396.16,7440.05,,4288.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.26,,,percent of total billed charges,,Paid in addition to inpatient services ,3396.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3720.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6564.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4376.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7440.05,,,percent of total billed charges,,,3938.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER THK6 50MM 47MM MRI,10293811,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,8753.00,2625.90,3676.26,7440.05,,4288.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.26,,,percent of total billed charges,,Paid in addition to outpatient services ,4415.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3720.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6564.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4376.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6564.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7440.05,,,percent of total billed charges,,,4026.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX 4 NEUT 36X70,10293813,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX 4 NEUT 36X70,10293813,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX 4 NEUT 36X72,10293814,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX 4 NEUT 36X72,10293814,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX 4 NEUT 36X74,10293815,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX 4 NEUT 36X74,10293815,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX 4 NEUT 36X76,10293816,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX 4 NEUT 36X76,10293816,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 32X60MM,10293817,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 32X60MM,10293817,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 32X62MM,10293818,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 32X62MM,10293818,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 32X64MM,10293819,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 32X64MM,10293819,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 32X66MM,10293820,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 32X66MM,10293820,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX LIP LNR 32X68,10293821,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX LIP LNR 32X68,10293821,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX LIP LNR 32X70,10294316,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX LIP LNR 32X70,10294316,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX LIP LNR 32X72,10294317,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX LIP LNR 32X72,10294317,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX LIP LNR 32X74,10294318,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX LIP LNR 32X74,10294318,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX LIP LNR 32X76,10294319,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX LIP LNR 32X76,10294319,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ACETABULAR 36X68MM,10294320,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ACETABULAR 36X68MM,10294320,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX NEUT 36X70,10294321,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX NEUT 36X70,10294321,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ACETABULAR 36X72MM,10294322,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ACETABULAR 36X72MM,10294322,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX NEUT 36X74,10294323,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX NEUT 36X74,10294323,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ALTRX NEUT 36X76,10294324,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ALTRX NEUT 36X76,10294324,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12-14 OFFSET 22  4MM,10294325,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12-14 OFFSET 22  4MM,10294325,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12-14 OFFSET 22  7MM,10294326,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12-14 OFFSET 22  7MM,10294326,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12-14 OFFSET 271.5MM,10294327,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12-14 OFFSET 271.5MM,10294327,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12-14 OFFSET 28  5MM,10294328,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12-14 OFFSET 28  5MM,10294328,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12-14 OFFSET 288.5MM,10294329,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12-14 OFFSET 288.5MM,10294329,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL FX REUNION 8MM X_5586-0008 X_STRYKER,10294330,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11802.00,3540.60,4579.18,10031.70,,5782.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4956.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4579.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8851.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5901.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10031.70,,,percent of total billed charges,,,5310.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL FX REUNION 8MM X_5586-0008 X_STRYKER,10294330,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11802.00,3540.60,4956.84,10031.70,,5782.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4956.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5952.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8851.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5901.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8851.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10031.70,,,percent of total billed charges,,,5428.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING STR 6F 45CM,10294331,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,446.00,133.80,189.55,379.10,,275.63,,,percent of total billed charges,,,,,,,,service not payable,217.65,,,percent of total billed charges,,,224.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,,,,,,,334.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,223.0,,,percent of total billed charges,,,,,,,,service not payable,334.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,379.10,,,percent of total billed charges,,,205.16,,,percent of total billed charges,,,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING STR 7F 45CM,10294332,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,446.00,133.80,189.55,379.10,,275.63,,,percent of total billed charges,,,,,,,,service not payable,217.65,,,percent of total billed charges,,,224.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,,,,,,,334.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,223.0,,,percent of total billed charges,,,,,,,,service not payable,334.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,379.10,,,percent of total billed charges,,,205.16,,,percent of total billed charges,,,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE DERMAL 4X7CM,10294337,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,3721.00,1116.30,1581.42,3162.85,,2299.58,,,percent of total billed charges,,,,,,,,service not payable,1815.85,,,percent of total billed charges,,,1876.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.42,,,percent of total billed charges,,,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,,,,,,,service not payable,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3162.85,,,percent of total billed charges,,,1711.66,,,percent of total billed charges,,,,,,,,,2418.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2418.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE DERMAL 4X7CM,10294337,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,3721.00,1116.30,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BRACE THUMB RESTING SPLINT MED RT X_081620913 X_PE,10294340,CDM,0274,RC,L3923,HCPCS,,,,,,inpatient,facility,,,408.00,122.40,158.30,346.80,,,,,,,,,,,,,,,,,,,,158.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,306.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,346.80,,,percent of total billed charges,,,183.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRACE THUMB RESTING SPLINT MED RT X_081620913 X_PE,10294340,CDM,0274,RC,L3923,HCPCS,,,,,,outpatient,facility,,,408.00,122.40,67.25,346.80,,,,,,,,96.34,,,fee schedule,,,,,,,,,205.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,202.67,,,fee schedule,,,67.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",98.27,,,fee schedule,,,221.28,,,fee schedule,,,,,,,,,96.34,,,fee schedule,,,,,,,,,173.40,,,percent of total billed charges,,Paid in addition to outpatient services ,199.74,,,fee schedule,,,306.0,,,percent of total billed charges,,,96.34,,,fee schedule,,,67.25,,,fee schedule,,,98.27,,,fee schedule,,,204.0,,,percent of total billed charges,,Paid in addition to outpatient services ,96.34,,,fee schedule,,,306.0,,,percent of total billed charges,,,67.25,,,fee schedule,,,98.27,,,fee schedule,,,,,,,,,346.80,,,percent of total billed charges,,,187.68,,,percent of total billed charges,,,,,,,,,,,,,,,96.34,,,fee schedule,,,,,,,,,,,,,,,96.34,,,fee schedule,,,,,,,,,97.31,,,fee schedule,,,,,,,,
BRACE THUMB RESTING SPLINT MED LT X_081620905 X_PE,10294341,CDM,0274,RC,L3923,HCPCS,,,,,,inpatient,facility,,,408.00,122.40,158.30,346.80,,,,,,,,,,,,,,,,,,,,158.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,306.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,346.80,,,percent of total billed charges,,,183.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRACE THUMB RESTING SPLINT MED LT X_081620905 X_PE,10294341,CDM,0274,RC,L3923,HCPCS,,,,,,outpatient,facility,,,408.00,122.40,67.25,346.80,,,,,,,,96.34,,,fee schedule,,,,,,,,,205.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,202.67,,,fee schedule,,,67.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",98.27,,,fee schedule,,,221.28,,,fee schedule,,,,,,,,,96.34,,,fee schedule,,,,,,,,,173.40,,,percent of total billed charges,,Paid in addition to outpatient services ,199.74,,,fee schedule,,,306.0,,,percent of total billed charges,,,96.34,,,fee schedule,,,67.25,,,fee schedule,,,98.27,,,fee schedule,,,204.0,,,percent of total billed charges,,Paid in addition to outpatient services ,96.34,,,fee schedule,,,306.0,,,percent of total billed charges,,,67.25,,,fee schedule,,,98.27,,,fee schedule,,,,,,,,,346.80,,,percent of total billed charges,,,187.68,,,percent of total billed charges,,,,,,,,,,,,,,,96.34,,,fee schedule,,,,,,,,,,,,,,,96.34,,,fee schedule,,,,,,,,,97.31,,,fee schedule,,,,,,,,
STENT ENDOPRO 5MMX5CM 120CM X_VBHR050502A X_W L GO,10294343,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 5MMX5CM 120CM X_VBHR050502A X_W L GO,10294343,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPRO 5MMX10CM 120CM,10294344,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11703.00,3510.90,4540.76,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4540.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9947.55,,,percent of total billed charges,,,5266.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 5MMX10CM 120CM,10294344,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4915.26,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPRO 6MMX5CM 120CM,10294345,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10671.00,3201.30,4140.35,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4140.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9070.35,,,percent of total billed charges,,,4801.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 6MMX5CM 120CM,10294345,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4481.82,9070.35,,5228.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4481.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPRO 6MMX25CM 120CM,10294346,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,21703.00,6510.90,8420.76,18447.55,,10634.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9115.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8420.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9223.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16277.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18447.55,,,percent of total billed charges,,,9766.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 6MMX25CM 120CM,10294346,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,21703.00,6510.90,9115.26,18447.55,,10634.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9115.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10946.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9223.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16277.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16277.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18447.55,,,percent of total billed charges,,,9983.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPRO 7MMX10CM 120CM,10294347,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11703.00,3510.90,4540.76,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4540.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9947.55,,,percent of total billed charges,,,5266.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 7MMX10CM 120CM,10294347,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4915.26,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPRO 7MMX15CM 120CM,10294348,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13080.00,3924.00,5075.04,11118.0,,6409.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5493.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5075.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9810.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6540.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11118.0,,,percent of total billed charges,,,5886.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 7MMX15CM 120CM,10294348,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13080.00,3924.00,5493.60,11118.0,,6409.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5493.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6597.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5559.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9810.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6540.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9810.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11118.0,,,percent of total billed charges,,,6016.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
UA Microscopic,10294637,CDM,0300,RC,81001,CPT,,,,,,outpatient,facility,,,60.00,18.00,3.01,51.0,,13.46,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,3.11,,,fee schedule,,,10.04,,,fee schedule,,,6.62,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,6.56,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3.17,,,fee schedule,,,7.16,,,fee schedule,,,,,,,,,3.11,,,fee schedule,,,,,,,,,4.21,,,fee schedule,,,6.47,,,fee schedule,,,45.0,,,percent of total billed charges,,,3.11,,,fee schedule,,,3.01,,,fee schedule,,,3.17,,,fee schedule,,,4.95,,,fee schedule,,,3.11,,,fee schedule,,,45.0,,,percent of total billed charges,,,,,,,,,3.17,,,fee schedule,,,,,,,,,51.0,,,percent of total billed charges,,,27.60,,,percent of total billed charges,,,,,,,,,3.49,,,fee schedule,,,3.11,,,fee schedule,,,,,,,,,3.07,,,fee schedule,,,3.11,,,fee schedule,,,,,,,,,3.14,,,fee schedule,,,,,,,,
UA Microscopic,10294637,CDM,0300,RC,81001,CPT,410,EAPG,,,,outpatient,facility,,,60.00,18.00,3.49,29.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,25.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3.49,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3.49,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,21.70,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,23.87,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW QWIX 4.3X26MM X_111426SND X_INTEGRA LIFE,10296105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1536.00,460.80,595.97,1305.60,,,,,,,,,,,,,,,,,,,,595.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1152.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.60,,,percent of total billed charges,,,691.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW QWIX 4.3X26MM X_111426SND X_INTEGRA LIFE,10296105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1536.00,460.80,652.80,1305.60,,,,,,,,,,,,,service not payable,,,,,,,774.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,652.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1152.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1152.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1305.60,,,percent of total billed charges,,,706.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC LOCK ST 4.0X24MM,10296106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC LOCK ST 4.0X24MM,10296106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTIDIRECTION 3.5X32MM,10296107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTIDIRECTION 3.5X32MM,10296107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTIDIRECTION 3.5X26MM,10296108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTIDIRECTION 3.5X26MM,10296108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTIDIRECTION 3.5X28MM,10296109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTIDIRECTION 3.5X28MM,10296109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTIDIRECTION 3.5X42MM,10296110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTIDIRECTION 3.5X42MM,10296110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC LOCK ST 4.0X20MM,10296111,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC LOCK ST 4.0X20MM,10296111,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC LOCK ST 4.0X46MM,10296112,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC LOCK ST 4.0X46MM,10296112,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC LOCK ST 4.0X42MM,10296113,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC LOCK ST 4.0X42MM,10296113,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR ICD DR PRIMO MRI,10296114,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,23310.00,6993.00,9044.28,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9790.20,,,percent of total billed charges,,Paid in addition to inpatient services ,9044.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19813.5,,,percent of total billed charges,,,10489.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR ICD DR PRIMO MRI,10296114,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,23310.00,6993.00,9790.20,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9790.20,,,percent of total billed charges,,Paid in addition to outpatient services ,11757.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19813.5,,,percent of total billed charges,,,10722.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 17MM,10296115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 17MM,10296115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KNEE SZ 3 9MM,10296116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KNEE SZ 3 9MM,10296116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ3 13MM X_5534-A-313 X_STRYKER,10296117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ3 13MM X_5534-A-313 X_STRYKER,10296117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROCESSOR SOUND NUCLEUS 7 SAND X_P732101 X_COCHLEA,10296119,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,8854.00,2656.20,3435.35,7525.90,,4338.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3718.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3435.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6640.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4427.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7525.90,,,percent of total billed charges,,,3984.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCESSOR SOUND NUCLEUS 7 SAND X_P732101 X_COCHLEA,10296119,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,8854.00,2656.20,3718.68,7525.90,,4338.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3718.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4465.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3762.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6640.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4427.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6640.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7525.90,,,percent of total billed charges,,,4072.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE FIXED CORE 145CM,10296121,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,129.00,38.70,54.83,109.65,,79.72,,,percent of total billed charges,,,,,,,,service not payable,62.95,,,percent of total billed charges,,,65.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,54.83,,,percent of total billed charges,,,,,,,,,96.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,64.5,,,percent of total billed charges,,,,,,,,service not payable,96.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,109.65,,,percent of total billed charges,,,59.34,,,percent of total billed charges,,,,,,,,,83.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,83.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE HIWIRE 150CM,10296126,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,168.00,50.40,71.40,142.80,,103.82,,,percent of total billed charges,,,,,,,,service not payable,81.98,,,percent of total billed charges,,,84.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,71.40,,,percent of total billed charges,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,84.0,,,percent of total billed charges,,,,,,,,service not payable,126.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,142.80,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,109.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DRAINAGE 10F 30CM,10296127,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,577.83,,,percent of total billed charges,,,,,,,,service not payable,456.28,,,percent of total billed charges,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,607.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,607.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BIODESIGN 2.5X2.5CM,10296128,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,1258.00,377.40,488.10,1069.3,,,,,,,,,,,,,,,,,,,,488.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1069.3,,,percent of total billed charges,,,566.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BIODESIGN 2.5X2.5CM,10296128,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,1258.00,377.40,534.65,1069.3,,,,,,,,,,,,,service not payable,,,,,,,634.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,943.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,629.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,943.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1069.3,,,percent of total billed charges,,,578.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL ELAST 2.5MM 440MM,10298100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3687.00,1106.10,1430.56,3133.95,,,,,,,,,,,,,,,,,,,,1430.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1566.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3133.95,,,percent of total billed charges,,,1659.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL ELAST 2.5MM 440MM,10298100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3687.00,1106.10,1566.97,3133.95,,,,,,,,,,,,,service not payable,,,,,,,1859.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1566.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3133.95,,,percent of total billed charges,,,1696.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 2.5X32MM,10298101,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2313.00,693.90,897.44,1966.05,,,,,,,,,,,,,,,,,,,,897.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1734.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1156.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1966.05,,,percent of total billed charges,,,1040.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X32MM,10298101,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2313.00,693.90,983.02,1966.05,,,,,,,,,,,,,service not payable,,,,,,,1166.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,983.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1734.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1156.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1734.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1966.05,,,percent of total billed charges,,,1063.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 3X40X130,10298103,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT AORTIC 14F 32X32X49MM,10298104,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13499.00,4049.70,5237.61,11474.15,,6614.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5669.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5237.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5737.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10124.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6749.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11474.15,,,percent of total billed charges,,,6074.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT AORTIC 14F 32X32X49MM,10298104,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13499.00,4049.70,5669.58,11474.15,,6614.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5669.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6808.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5737.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10124.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6749.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10124.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11474.15,,,percent of total billed charges,,,6209.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE FB TIB BASE SZ 1 CEM,10298106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE FB TIB BASE SZ 1 CEM,10298106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE KNEE ATTUNE FIXED SZ 10,10298107,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE KNEE ATTUNE FIXED SZ 10,10298107,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC DOME 6.5X55MM,10298108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC DOME 6.5X55MM,10298108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC DOME 6.5X65MM,10298109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC DOME 6.5X65MM,10298109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC DOME 6.5X70MM,10298110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC DOME 6.5X70MM,10298110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CORAIL SZ20 135DX170,10298111,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14162.00,4248.60,5494.86,12037.70,,6939.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5948.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5494.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6018.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10621.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7081.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12037.70,,,percent of total billed charges,,,6372.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CORAIL SZ20 135DX170,10298111,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14162.00,4248.60,5948.04,12037.70,,6939.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5948.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7143.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6018.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7081.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10621.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12037.70,,,percent of total billed charges,,,6514.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CORAIL SZ10 135DX140,10298112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CORAIL SZ10 135DX140,10298112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CORAIL SZ11 135DX145,10298113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CORAIL SZ11 135DX145,10298113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CORAIL SZ12 135DX150,10298114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CORAIL SZ12 135DX150,10298114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CORAIL SZ9 135DX130,10298115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CORAIL SZ9 135DX130,10298115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM CORAIL SZ8 135DX115,10298116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM CORAIL SZ8 135DX115,10298116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 11/13 32 6MM,10298117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 11/13 32 6MM,10298117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 11/13 28 0MM,10298118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 11/13 28 0MM,10298118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 11/13 28 3MM,10298119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 11/13 28 3MM,10298119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 11/13 36 0MM,10298120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 11/13 36 0MM,10298120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 11/13 36 3MM,10298121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 11/13 36 3MM,10298121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 11/13 36 9MM,10298122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 11/13 36 9MM,10298122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TRI-LOCK SZ12 119MM,10298123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TRI-LOCK SZ12 119MM,10298123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT KNEE PATELLA WIDE,10298124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT KNEE PATELLA WIDE,10298124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT KNEE PATELLA LG,10298125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT KNEE PATELLA LG,10298125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT PATELLA LCS LG PLUS,10298126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT PATELLA LCS LG PLUS,10298126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT PATELLA LCS STD LP,10298127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT PATELLA LCS STD LP,10298127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY KNEE LCS COMP MBT SZ1,10298128,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY KNEE LCS COMP MBT SZ1,10298128,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY KNEE LCS COMP MBT SZ7,10298129,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY KNEE LCS COMP MBT SZ7,10298129,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ2 15MM,10298130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ2 15MM,10298130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ2 17.5MM,10298131,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ2 17.5MM,10298131,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ2.5 17.5,10298132,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ2.5 17.5,10298132,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ4 17.5MM,10298133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ4 17.5MM,10298133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ5 17.5MM,10298134,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ5 17.5MM,10298134,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SIGMA SZ6 17.5MM,10298135,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SIGMA SZ6 17.5MM,10298135,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SGMA PFC SZ2.5 17.5,10298136,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SGMA PFC SZ2.5 17.5,10298136,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA PFC SZ5 17.5,10298137,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA PFC SZ5 17.5,10298137,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR 100 62MM,10298138,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR 100 62MM,10298138,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR 100 66MM,10298139,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR 100 66MM,10298139,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 48X28MM,10298140,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 48X28MM,10298140,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 50X28MM,10298141,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 50X28MM,10298141,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIP PIN 50X28MM,10298142,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIP PIN 50X28MM,10298142,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 52X28MM,10298143,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 52X28MM,10298143,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIP PIN 52X28MM,10298144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIP PIN 52X28MM,10298144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 54X28MM,10298145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 54X28MM,10298145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIP PIN 54X28MM,10298146,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIP PIN 54X28MM,10298146,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 56X28MM,10298147,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 56X28MM,10298147,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIP PIN 56X28MM,10298148,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIP PIN 56X28MM,10298148,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 58X28MM,10298149,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 58X28MM,10298149,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIP PIN 58X28MM,10298150,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIP PIN 58X28MM,10298150,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP LIPPED XLINK 58X28MM,10298151,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP LIPPED XLINK 58X28MM,10298151,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEMORAL HIP NEUT 60X28MM,10298152,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEMORAL HIP NEUT 60X28MM,10298152,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 60X28MM,10298153,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 60X28MM,10298153,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER TIB NEUTRAL 4 62X28MM,10298154,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER TIB NEUTRAL 4 62X28MM,10298154,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 62X28MM,10298155,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 62X28MM,10298155,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM XLINK LIPPED 62X28MM,10298156,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM XLINK LIPPED 62X28MM,10298156,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP NEUTRAL 64X28MM,10298157,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP NEUTRAL 64X28MM,10298157,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 64X28MM,10298158,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 64X28MM,10298158,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM XLINK LIPPED 28X64MM,10298159,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM XLINK LIPPED 28X64MM,10298159,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP NEUTRAL 66X28MM,10298160,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP NEUTRAL 66X28MM,10298160,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM HIP LIPPED 66X28MM,10298161,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM HIP LIPPED 66X28MM,10298161,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER FEM XLINK LIPPED 28X66MM,10298162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER FEM XLINK LIPPED 28X66MM,10298162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ3N LT X_71421243 X_SMITH NEPHE,10298972,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7549.00,2264.70,2929.01,6416.65,,3699.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3170.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2929.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3208.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5661.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3774.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6416.65,,,percent of total billed charges,,,3397.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ3N LT X_71421243 X_SMITH NEPHE,10298972,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7549.00,2264.70,3170.58,6416.65,,3699.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3170.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3807.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3208.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5661.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3774.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5661.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6416.65,,,percent of total billed charges,,,3472.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE NONVASC 0.035INX145CM X_G27033 X_COOK ME,10298974,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,212.00,63.60,90.10,180.20,,131.02,,,percent of total billed charges,,,,,,,,service not payable,103.46,,,percent of total billed charges,,,106.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,90.10,,,percent of total billed charges,,,,,,,,,159.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,106.0,,,percent of total billed charges,,,,,,,,service not payable,159.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,180.20,,,percent of total billed charges,,,97.52,,,percent of total billed charges,,,,,,,,,137.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,137.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE V-14 0.014IN 300CM,10298978,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,649.00,194.70,275.82,551.65,,401.08,,,percent of total billed charges,,,,,,,,service not payable,316.71,,,percent of total billed charges,,,327.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,275.82,,,percent of total billed charges,,,,,,,,,486.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,324.5,,,percent of total billed charges,,,,,,,,service not payable,486.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,551.65,,,percent of total billed charges,,,298.54,,,percent of total billed charges,,,,,,,,,421.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,421.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STYLET VAN BUREN CRV 6F,10298980,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,203.00,60.90,86.28,172.55,,125.45,,,percent of total billed charges,,,,,,,,service not payable,99.06,,,percent of total billed charges,,,102.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,86.28,,,percent of total billed charges,,,,,,,,,152.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,101.5,,,percent of total billed charges,,,,,,,,service not payable,152.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,172.55,,,percent of total billed charges,,,93.38,,,percent of total billed charges,,,,,,,,,131.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,131.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cell Surface Markers ea addl,10299476,CDM,0311,RC,88185,CPT,,,,,,outpatient,facility,,,15.00,4.50,6.90,45.82,,15.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,15.0,,,fee schedule,,,45.82,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.91,,,fee schedule,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.18,,,fee schedule,,,,,,,,service not payable,11.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12.75,,,percent of total billed charges,,,6.90,,,percent of total billed charges,,,,,,,,,25.58,,,fee schedule,,,,,,,,service not payable,,,,,,,22.55,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cell Surface Markers ea addl,10299476,CDM,0311,RC,88185,CPT,391,EAPG,,,,outpatient,facility,,,15.00,4.50,15.0,377.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,320.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,59.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,65.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Addl 30 Min Increments CC > 74,10299979,CDM,0450,RC,99292,CPT,,,,,,outpatient,facility,,,828.00,248.40,190.44,3660.0,,511.70,,,percent of total billed charges,,,,,,,,service not payable,404.06,,,percent of total billed charges,,,417.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3111.0,,,fee schedule,,,,,,,,,621.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3660.0,,,fee schedule,,,,,,,,service not payable,621.0,,,percent of total billed charges,,,190.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,703.80,,,percent of total billed charges,,,380.88,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Addl 30 Min Increments CC > 74,10299979,CDM,0450,RC,99292,CPT,852,EAPG,,,,outpatient,facility,,,828.00,248.40,254.45,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW BIOCOMP INTERF 10X20MM,10300574,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIOCOMP INTERF 10X20MM,10300574,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2MM 6H X_50-766-06 X_KLS MARTIN L P,10300576,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2560.00,768.00,993.28,2176.0,,,,,,,,,,,,,,,,,,,,993.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1920.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1280.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2176.0,,,percent of total billed charges,,,1152.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2MM 6H X_50-766-06 X_KLS MARTIN L P,10300576,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2560.00,768.00,1088.0,2176.0,,,,,,,,,,,,,service not payable,,,,,,,1291.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1088.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1920.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1280.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1920.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2176.0,,,percent of total billed charges,,,1177.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT BL SZ1 LENGTH 1.9MM,10300577,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT BL SZ1 LENGTH 1.9MM,10300577,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ELEVATOR NAIL DOUBLE ENDED 5.7,10300581,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,215.00,64.50,83.42,182.75,,,,,,,,,,,,,,,,,,,,83.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,161.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.75,,,percent of total billed charges,,,96.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELEVATOR NAIL DOUBLE ENDED 5.7,10300581,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,215.00,64.50,91.38,182.75,,,,,,,,,,,,,service not payable,,,,,,,108.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,91.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,161.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,107.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,161.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,182.75,,,percent of total billed charges,,,98.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN ASNIS 3 TI 6.5X105,10300582,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN ASNIS 3 TI 6.5X105,10300582,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL KIT TI 13X340MM 125DEG RT X_3425-3340S X_STRY,10300583,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL KIT TI 13X340MM 125DEG RT X_3425-3340S X_STRY,10300583,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TI FEM ELASTIC 440X2.5MM,10300584,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2431.00,729.30,943.23,2066.35,,,,,,,,,,,,,,,,,,,,943.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1033.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1823.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1215.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2066.35,,,percent of total billed charges,,,1093.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TI FEM ELASTIC 440X2.5MM,10300584,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2431.00,729.30,1033.18,2066.35,,,,,,,,,,,,,service not payable,,,,,,,1226.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1033.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1823.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1215.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1823.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2066.35,,,percent of total billed charges,,,1118.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T10 FT 3.5X24MM,10301383,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T10 FT 3.5X24MM,10301383,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD STIMULATOR NEUROMOD,10301384,CDM,0274,RC,L9900,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD STIMULATOR NEUROMOD,10301384,CDM,0274,RC,L9900,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IVUS ULTRA ICE PLUS,10301385,CDM,0272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,2565.94,,,percent of total billed charges,,,,,,,,service not payable,2026.18,,,percent of total billed charges,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,2698.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2698.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR RT 3H 7 PEG NARROW X_VLBPR-3-7N X_TRI-,10301387,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3721.00,1116.30,1443.75,3162.85,,,,,,,,,,,,,,,,,,,,1443.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3162.85,,,percent of total billed charges,,,1674.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR RT 3H 7 PEG NARROW X_VLBPR-3-7N X_TRI-,10301387,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3721.00,1116.30,1581.42,3162.85,,,,,,,,,,,,,service not payable,,,,,,,1876.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3162.85,,,percent of total billed charges,,,1711.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PS X3 2 13MM,10301388,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PS X3 2 13MM,10301388,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLOBAL UNITE FX RSA EPI SZ1 R,10301390,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLOBAL UNITE FX RSA EPI SZ1 R,10301390,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLOBAL UNITE FX RSA EPI SZ1 L,10301391,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLOBAL UNITE FX RSA EPI SZ1 L,10301391,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLOBAL UNITE FX RSA EPI 1,10301392,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLOBAL UNITE FX RSA EPI 1,10301392,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HIV 1 by Quantitative NAAT,10301547,CDM,0300,RC,87536,CPT,,,,,,outpatient,facility,,,115.00,34.50,52.90,192.33,,115.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,83.40,,,fee schedule,,,115.0,,,fee schedule,,,177.47,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,176.16,,,fee schedule,,,80.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",85.07,,,fee schedule,,,192.33,,,fee schedule,,,,,,,,,83.40,,,fee schedule,,,,,,,,,109.53,,,fee schedule,,,173.60,,,fee schedule,,,86.25,,,percent of total billed charges,,,83.40,,,fee schedule,,,80.85,,,fee schedule,,,85.07,,,fee schedule,,,128.82,,,fee schedule,,,83.40,,,fee schedule,,,86.25,,,percent of total billed charges,,,,,,,,,85.07,,,fee schedule,,,,,,,,,97.75,,,percent of total billed charges,,,52.90,,,percent of total billed charges,,,,,,,,,93.61,,,fee schedule,,,83.40,,,fee schedule,,,,,,,,,82.55,,,fee schedule,,,83.40,,,fee schedule,,,,,,,,,84.23,,,fee schedule,,,,,,,,
HIV 1 by Quantitative NAAT,10301547,CDM,0300,RC,87536,CPT,397,EAPG,,,,outpatient,facility,,,115.00,34.50,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Antinuclear Antibody (ANA) HEp-2 IgG,10301576,CDM,0300,RC,86039,CPT,,,,,,outpatient,facility,,,14.00,4.20,6.44,25.22,,14.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.94,,,fee schedule,,,14.0,,,fee schedule,,,23.27,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,23.10,,,fee schedule,,,10.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.16,,,fee schedule,,,25.22,,,fee schedule,,,,,,,,,10.94,,,fee schedule,,,,,,,,,14.32,,,fee schedule,,,22.77,,,fee schedule,,,10.5,,,percent of total billed charges,,,10.94,,,fee schedule,,,10.6,,,fee schedule,,,11.16,,,fee schedule,,,16.85,,,fee schedule,,,10.94,,,fee schedule,,,10.5,,,percent of total billed charges,,,,,,,,,11.16,,,fee schedule,,,,,,,,,11.9,,,percent of total billed charges,,,6.44,,,percent of total billed charges,,,,,,,,,12.28,,,fee schedule,,,10.94,,,fee schedule,,,,,,,,,10.83,,,fee schedule,,,10.94,,,fee schedule,,,,,,,,,11.04,,,fee schedule,,,,,,,,
Antinuclear Antibody (ANA) HEp-2 IgG,10301576,CDM,0300,RC,86039,CPT,394,EAPG,,,,outpatient,facility,,,14.00,4.20,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Hepatitis B Virus (HBV) by Quant NAAT,10301581,CDM,0300,RC,87517,CPT,,,,,,outpatient,facility,,,148.00,44.40,40.70,148.0,,148.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,41.98,,,fee schedule,,,135.82,,,fee schedule,,,89.35,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,88.68,,,fee schedule,,,40.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",42.82,,,fee schedule,,,96.82,,,fee schedule,,,,,,,,,41.98,,,fee schedule,,,,,,,,,55.18,,,fee schedule,,,87.39,,,fee schedule,,,111.0,,,percent of total billed charges,,,41.98,,,fee schedule,,,40.70,,,fee schedule,,,42.82,,,fee schedule,,,64.89,,,fee schedule,,,41.98,,,fee schedule,,,111.0,,,percent of total billed charges,,,,,,,,,42.82,,,fee schedule,,,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,47.12,,,fee schedule,,,41.98,,,fee schedule,,,,,,,,,41.55,,,fee schedule,,,41.98,,,fee schedule,,,,,,,,,42.40,,,fee schedule,,,,,,,,
Hepatitis B Virus (HBV) by Quant NAAT,10301581,CDM,0300,RC,87517,CPT,397,EAPG,,,,outpatient,facility,,,148.00,44.40,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PIN HINGE KNEE SIGMA LT XS,10302391,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2665.00,799.50,1034.02,2265.25,,,,,,,,,,,,,,,,,,,,1034.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2265.25,,,percent of total billed charges,,,1199.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HINGE KNEE SIGMA LT XS,10302391,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2665.00,799.50,1132.62,2265.25,,,,,,,,,,,,,service not payable,,,,,,,1344.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1132.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1998.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1332.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1998.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2265.25,,,percent of total billed charges,,,1225.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE PST LMB 14X23MMX6D-11MM X_48951146 X_STRYKER,10302392,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PST LMB 14X23MMX6D-11MM X_48951146 X_STRYKER,10302392,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE BRIGADE 8X34X24 10DEG X_6951810 X_NUVASIVE,10302393,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE BRIGADE 8X34X24 10DEG X_6951810 X_NUVASIVE,10302393,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN FIXATION 12MM X_7881001 X_NUVASIVE,10302394,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN FIXATION 12MM X_7881001 X_NUVASIVE,10302394,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KNEE SZ 5 9MM,10302395,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KNEE SZ 5 9MM,10302395,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLYAXIAL 5X50MM,10302396,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLYAXIAL 5X50MM,10302396,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RAD POST TI 5.5X100MM,10302397,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5465.00,1639.50,2120.42,4645.25,,2677.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2120.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4098.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2732.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4645.25,,,percent of total billed charges,,,2459.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RAD POST TI 5.5X100MM,10302397,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5465.00,1639.50,2295.30,4645.25,,2677.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2756.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2322.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4098.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2732.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4098.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4645.25,,,percent of total billed charges,,,2513.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RT- Super Dimension Electromagnetic Navigation,10302473,CDM,0490,RC,31627,CPT,,,,,,outpatient,facility,,,2295.00,688.50,1055.7,2912.34,,2295.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,1157.60,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT ACHILLES TENDON 20MM,10302857,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,6950.00,2085.00,2696.60,5907.5,,3405.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2919.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2696.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5907.5,,,percent of total billed charges,,,3127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT ACHILLES TENDON 20MM,10302857,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,6950.00,2085.00,2919.0,5907.5,,3405.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2919.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3505.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5907.5,,,percent of total billed charges,,,3197.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ARTHROCELL 2.5CC,10302858,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTHROCELL 2.5CC,10302858,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATEAU TIB CEM 65X46MM X_NX052Z X_AESCULAP,10302859,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3377.00,1013.10,1310.28,2870.45,,,,,,,,,,,,,,,,,,,,1310.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1435.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2870.45,,,percent of total billed charges,,,1519.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATEAU TIB CEM 65X46MM X_NX052Z X_AESCULAP,10302859,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3377.00,1013.10,1435.22,2870.45,,,,,,,,,,,,,service not payable,,,,,,,1703.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1435.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2870.45,,,percent of total billed charges,,,1553.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CERAMENT GRAFT BONE 5ML,10302860,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CERAMENT GRAFT BONE 5ML,10302860,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CERAMENT GRAFT BONE 5ML,10302860,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,4263.00,1278.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CERAMENT BONE VOID FILLER 10ML,10302861,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,8530.00,2559.00,3309.64,7250.5,,4179.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3582.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3309.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3625.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6397.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4265.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7250.5,,,percent of total billed charges,,,3838.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CERAMENT BONE VOID FILLER 10ML,10302861,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,8530.00,2559.00,3582.60,7250.5,,4179.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3582.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4302.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3625.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6397.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4265.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6397.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7250.5,,,percent of total billed charges,,,3923.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CERAMENT BONE VOID FILLER 10ML,10302861,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,8530.00,2559.00,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE FILLER VOID 18ML X_A0210-11 X_BONESUPPORT INC,10302862,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,15326.00,4597.80,5946.49,13027.1,,7509.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6436.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5946.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6513.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11494.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7663.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13027.1,,,percent of total billed charges,,,6896.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BONE FILLER VOID 18ML X_A0210-11 X_BONESUPPORT INC,10302862,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,15326.00,4597.80,6436.92,13027.1,,7509.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6436.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7730.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6513.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11494.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7663.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11494.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13027.1,,,percent of total billed charges,,,7049.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BONE FILLER VOID 18ML X_A0210-11 X_BONESUPPORT INC,10302862,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,15326.00,4597.80,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH KIT HEMODIALYSIS 32CM,10302865,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.58,1393.15,,1012.9,,,percent of total billed charges,,,,,,,,service not payable,799.83,,,percent of total billed charges,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.58,,,percent of total billed charges,,,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,1065.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1065.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE ADPT FEM UNIV V40 X_6519-T-100 X_STRYKER OR,10302998,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE ADPT FEM UNIV V40 X_6519-T-100 X_STRYKER OR,10302998,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HALLULOCKS SZ4 RT X_290160SND X_INTEGRA LIFE,10302999,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5104.00,1531.20,1980.35,4338.40,,2500.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2143.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1980.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2169.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3828.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2552.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4338.40,,,percent of total billed charges,,,2296.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HALLULOCKS SZ4 RT X_290160SND X_INTEGRA LIFE,10302999,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5104.00,1531.20,2143.68,4338.40,,2500.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2143.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2574.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2169.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3828.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2552.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3828.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4338.40,,,percent of total billed charges,,,2347.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM IMPLANT 6MM,10303000,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7016.00,2104.80,2722.21,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2722.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5963.60,,,percent of total billed charges,,,3157.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM IMPLANT 6MM,10303000,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7016.00,2104.80,2946.72,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3538.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5963.60,,,percent of total billed charges,,,3227.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RADIAL HEAD IMPLANT 22MM,10303001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7016.00,2104.80,2722.21,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2722.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5963.60,,,percent of total billed charges,,,3157.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RADIAL HEAD IMPLANT 22MM,10303001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7016.00,2104.80,2946.72,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3538.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5963.60,,,percent of total billed charges,,,3227.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUFF URINARY SPHINCTER AMS 5CM,10303002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20057.00,6017.10,7782.12,17048.45,,9827.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8423.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7782.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8524.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15042.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10028.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17048.45,,,percent of total billed charges,,,9025.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUFF URINARY SPHINCTER AMS 5CM,10303002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20057.00,6017.10,8423.94,17048.45,,9827.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8423.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10116.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8524.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15042.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10028.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15042.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17048.45,,,percent of total billed charges,,,9226.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE STRIKE NUMBER 41 X_6541-1-805 X_STRYKER ORTH,10303003,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2515.00,754.50,975.82,2137.75,,,,,,,,,,,,,,,,,,,,975.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1886.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1257.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2137.75,,,percent of total billed charges,,,1131.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE STRIKE NUMBER 41 X_6541-1-805 X_STRYKER ORTH,10303003,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2515.00,754.50,1068.88,2137.75,,,,,,,,,,,,,service not payable,,,,,,,1268.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1886.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1886.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2137.75,,,percent of total billed charges,,,1156.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER GUIDE 31/32MM X_MP0031/32-12 X_AGI MEDI,10303004,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,354.73,,,percent of total billed charges,,,,,,,,service not payable,280.11,,,percent of total billed charges,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,373.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,373.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 10MM,10303006,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 10MM,10303006,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 12.5MM,10303007,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 12.5MM,10303007,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 15MM,10303008,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 15MM,10303008,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 17.5MM,10303009,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 17.5MM,10303009,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 20MM,10303010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 20MM,10303010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 10MM_Johnson and Johnson Hea,10303011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 10MM_Johnson and Johnson Hea,10303011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 12.5MM_Johnson and Johnson H,10303012,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 12.5MM_Johnson and Johnson H,10303012,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 15MM_Johnson and Johnson Hea,10303013,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 15MM_Johnson and Johnson Hea,10303013,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 17.5MM_Johnson and Johnson H,10303014,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 17.5MM_Johnson and Johnson H,10303014,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD LG 20MM_Johnson and Johnson Hea,10303015,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD LG 20MM_Johnson and Johnson Hea,10303015,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD MD 10MM,10303016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD MD 10MM,10303016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD MD 12.5MM,10303017,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD MD 12.5MM,10303017,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD MD 15MM,10303018,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD MD 15MM,10303018,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD MD 17MM,10303019,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD MD 17MM,10303019,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD MD 20MM,10303020,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD MD 20MM,10303020,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 10MM,10303021,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 10MM,10303021,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 12.5MM,10303022,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 12.5MM,10303022,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 15MM,10303023,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 15MM,10303023,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 17.5MM,10303024,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 17.5MM,10303024,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 20MM,10303025,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 20MM,10303025,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 10MM_Johnson and Johnson Hea,10303026,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 10MM_Johnson and Johnson Hea,10303026,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 12.5MM_Johnson and Johnson H,10303027,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 12.5MM_Johnson and Johnson H,10303027,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 15MM_Johnson and Johnson Hea,10303028,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 15MM_Johnson and Johnson Hea,10303028,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 17.5MM_Johnson and Johnson H,10303029,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 17.5MM_Johnson and Johnson H,10303029,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD SM 20MM_Johnson and Johnson Hea,10303030,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD SM 20MM_Johnson and Johnson Hea,10303030,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD  10MM,10303031,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD  10MM,10303031,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD  12.5MM,10303032,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD  12.5MM,10303032,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD  15MM,10303033,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD  15MM,10303033,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD  17.5MM,10303034,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD  17.5MM,10303034,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD  20MM,10303035,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD  20MM,10303035,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD 10MM_Johnson and Johnson Health,10303036,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD 10MM_Johnson and Johnson Health,10303036,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD 12.5MM_Johnson and Johnson Heal,10303037,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD 12.5MM_Johnson and Johnson Heal,10303037,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD 15MM_Johnson and Johnson Health,10303038,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD 15MM_Johnson and Johnson Health,10303038,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD 17.5MM_Johnson and Johnson Heal,10303039,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD 17.5MM_Johnson and Johnson Heal,10303039,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB LCS STD 20MM_Johnson and Johnson Health,10303040,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB LCS STD 20MM_Johnson and Johnson Health,10303040,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN BONE FIXATION SMOOTH 3IN,10303041,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,932.00,279.60,361.62,792.20,,,,,,,,,,,,,,,,,,,,361.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792.20,,,percent of total billed charges,,,419.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN BONE FIXATION SMOOTH 3IN,10303041,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,932.00,279.60,396.10,792.20,,,,,,,,,,,,,service not payable,,,,,,,470.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,699.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,792.20,,,percent of total billed charges,,,428.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE PATELLA LCS WIDE,10303042,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE PATELLA LCS WIDE,10303042,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE PATELLA LCS STD,10303043,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE PATELLA LCS STD,10303043,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR ICD DR PRIMO MRI DC,10303044,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,23310.00,6993.00,9044.28,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9790.20,,,percent of total billed charges,,Paid in addition to inpatient services ,9044.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19813.5,,,percent of total billed charges,,,10489.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR ICD DR PRIMO MRI DC,10303044,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,23310.00,6993.00,9790.20,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9790.20,,,percent of total billed charges,,Paid in addition to outpatient services ,11757.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19813.5,,,percent of total billed charges,,,10722.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT KNEE PATELLA LCS MD,10303045,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT KNEE PATELLA LCS MD,10303045,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS FEMORAL RT SZ 5 CEM,10304392,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEMORAL RT SZ 5 CEM,10304392,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD CAPSURE FIX 4076 45CM,10304396,CDM,0278,RC,C1898,HCPCS,,,,,,inpatient,facility,,,2223.00,666.90,862.52,1889.55,,,,,,,,,,,,,,,,,,,,862.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,944.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1889.55,,,percent of total billed charges,,,1000.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD CAPSURE FIX 4076 45CM,10304396,CDM,0278,RC,C1898,HCPCS,,,,,,outpatient,facility,,,2223.00,666.90,944.77,1889.55,,,,,,,,,,,,,service not payable,,,,,,,1121.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,944.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1667.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1889.55,,,percent of total billed charges,,,1022.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP NERVE COLLAGEN 4MMX2.5CM,10304397,CDM,0278,RC,C9353,HCPCS,,,,,,inpatient,facility,,,5130.00,1539.00,1990.44,4360.5,,2513.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2154.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1990.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2180.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3847.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2565.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4360.5,,,percent of total billed charges,,,2308.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WRAP NERVE COLLAGEN 4MMX2.5CM,10304397,CDM,0278,RC,C9353,HCPCS,,,,,,outpatient,facility,,,5130.00,1539.00,2154.60,4360.5,,2513.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2154.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2587.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2180.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3847.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2565.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3847.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4360.5,,,percent of total billed charges,,,2359.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP NERVE COLLAGEN 4MMX2.5CM,10304397,CDM,0278,RC,C9353,HCPCS,455,EAPG,,,,outpatient,facility,,,5130.00,1539.00,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BLNT 4X46MM X_AR-5051-46 X_ARTHREX INC,10304398,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BLNT 4X46MM X_AR-5051-46 X_ARTHREX INC,10304398,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN BLNT 4X44MM X_AR-5051-44 X_ARTHREX INC,10304399,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BLNT 4X44MM X_AR-5051-44 X_ARTHREX INC,10304399,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER 7.0MM X_AR-8870-W X_ARTHREX INC,10304400,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,176.00,52.80,68.29,149.60,,,,,,,,,,,,,,,,,,,,68.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,132.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.60,,,percent of total billed charges,,,79.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER 7.0MM X_AR-8870-W X_ARTHREX INC,10304400,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,176.00,52.80,74.80,149.60,,,,,,,,,,,,,service not payable,,,,,,,88.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,74.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,132.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,88.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,132.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,149.60,,,percent of total billed charges,,,80.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 4.1X28MM X_626828 X_STRYKER ORTHOPAEDICS,10304877,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1360.00,408.00,527.68,1156.0,,,,,,,,,,,,,,,,,,,,527.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,,612.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 4.1X28MM X_626828 X_STRYKER ORTHOPAEDICS,10304877,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1360.00,408.00,578.0,1156.0,,,,,,,,,,,,,service not payable,,,,,,,685.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,,625.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE FIBERTAPE 1/2 CIR SZ 2,10304879,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,416.00,124.80,161.41,353.60,,,,,,,,,,,,,,,,,,,,161.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,312.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,208.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.60,,,percent of total billed charges,,,187.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE FIBERTAPE 1/2 CIR SZ 2,10304879,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,416.00,124.80,176.80,353.60,,,,,,,,,,,,,service not payable,,,,,,,209.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,176.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,312.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,208.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,312.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,353.60,,,percent of total billed charges,,,191.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACK PIN GUIDEWIRE RAP-PAC 1.2,10304880,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1910.00,573.00,811.75,1623.5,,1180.38,,,percent of total billed charges,,,,,,,,service not payable,932.08,,,percent of total billed charges,,,963.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,811.75,,,percent of total billed charges,,,,,,,,,1432.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,955.0,,,percent of total billed charges,,,,,,,,service not payable,1432.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1623.5,,,percent of total billed charges,,,878.60,,,percent of total billed charges,,,,,,,,,1241.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1241.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE 1.35MM,10304882,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,service not payable,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,service not payable,168.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,145.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 20.0 D 6MM X_ZXR00-20.0 X_PREC,10304885,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 20.0 D 6MM X_ZXR00-20.0 X_PREC,10304885,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Differential (Manual),10304968,CDM,0300,RC,85007,CPT,,,,,,outpatient,facility,,,37.00,11.10,3.61,31.45,,14.61,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,3.72,,,fee schedule,,,10.9,,,fee schedule,,,7.92,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,7.87,,,fee schedule,,,3.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3.79,,,fee schedule,,,8.59,,,fee schedule,,,,,,,,,3.72,,,fee schedule,,,,,,,,,5.05,,,fee schedule,,,7.75,,,fee schedule,,,27.75,,,percent of total billed charges,,,3.72,,,fee schedule,,,3.61,,,fee schedule,,,3.79,,,fee schedule,,,5.94,,,fee schedule,,,3.72,,,fee schedule,,,27.75,,,percent of total billed charges,,,,,,,,,3.79,,,fee schedule,,,,,,,,,31.45,,,percent of total billed charges,,,17.02,,,percent of total billed charges,,,,,,,,,4.18,,,fee schedule,,,3.72,,,fee schedule,,,,,,,,,3.69,,,fee schedule,,,3.72,,,fee schedule,,,,,,,,,3.76,,,fee schedule,,,,,,,,
Differential (Manual),10304968,CDM,0300,RC,85007,CPT,408,EAPG,,,,outpatient,facility,,,37.00,11.10,6.99,27.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,22.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,25.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Differntial (Auto),10304970,CDM,0300,RC,85025,CPT,,,,,,outpatient,facility,,,87.00,26.10,7.38,73.95,,19.73,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.61,,,fee schedule,,,14.73,,,fee schedule,,,16.21,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,16.08,,,fee schedule,,,7.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.76,,,fee schedule,,,17.56,,,fee schedule,,,,,,,,,7.61,,,fee schedule,,,,,,,,,10.12,,,fee schedule,,,15.85,,,fee schedule,,,65.25,,,percent of total billed charges,,,7.61,,,fee schedule,,,7.38,,,fee schedule,,,7.76,,,fee schedule,,,11.9,,,fee schedule,,,7.61,,,fee schedule,,,65.25,,,percent of total billed charges,,,,,,,,,7.76,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,8.55,,,fee schedule,,,7.61,,,fee schedule,,,,,,,,,7.54,,,fee schedule,,,7.61,,,fee schedule,,,,,,,,,7.69,,,fee schedule,,,,,,,,
Differntial (Auto),10304970,CDM,0300,RC,85025,CPT,408,EAPG,,,,outpatient,facility,,,87.00,26.10,6.99,27.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,22.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,25.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR TENDON,10306174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR TENDON,10306174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE MFIX 6.5MM S-ULT,10306175,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2066.00,619.80,801.61,1756.10,,,,,,,,,,,,,,,,,,,,801.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1549.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1756.10,,,percent of total billed charges,,,929.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE MFIX 6.5MM S-ULT,10306175,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2066.00,619.80,878.05,1756.10,,,,,,,,,,,,,service not payable,,,,,,,1042.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1756.10,,,percent of total billed charges,,,950.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN BLNT 4X34 X_AR-5051-34 X_ARTHREX INC,10306177,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BLNT 4X34 X_AR-5051-34 X_ARTHREX INC,10306177,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LO-PRO 38X4MM,10306178,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LO-PRO 38X4MM,10306178,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT AORTIC EXT 32X32X70 X_ETTF3232C70E X_M,10306179,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,22348.00,6704.40,8671.02,18995.80,,10950.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9386.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8671.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9497.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16761.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11174.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18995.80,,,percent of total billed charges,,,10056.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT AORTIC EXT 32X32X70 X_ETTF3232C70E X_M,10306179,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,22348.00,6704.40,9386.16,18995.80,,10950.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9386.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11272.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9497.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16761.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11174.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16761.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18995.80,,,percent of total billed charges,,,10280.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEMORAL ACET 62MM,10306180,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEMORAL ACET 62MM,10306180,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SLIM 6H 43MM X_626966 X_STRYKER,10306182,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5017.00,1505.10,1946.60,4264.45,,2458.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2107.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1946.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2132.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4264.45,,,percent of total billed charges,,,2257.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SLIM 6H 43MM X_626966 X_STRYKER,10306182,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5017.00,1505.10,2107.14,4264.45,,2458.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2107.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2530.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2132.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4264.45,,,percent of total billed charges,,,2307.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cellavision Diff - Diff Type,10308205,CDM,0300,RC,85027,CPT,,,,,,outpatient,facility,,,116.00,34.80,6.15,98.60,,27.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.34,,,fee schedule,,,20.53,,,fee schedule,,,13.49,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.39,,,fee schedule,,,6.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.47,,,fee schedule,,,14.62,,,fee schedule,,,,,,,,,6.34,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.20,,,fee schedule,,,87.0,,,percent of total billed charges,,,6.34,,,fee schedule,,,6.15,,,fee schedule,,,6.47,,,fee schedule,,,9.92,,,fee schedule,,,6.34,,,fee schedule,,,87.0,,,percent of total billed charges,,,,,,,,,6.47,,,fee schedule,,,,,,,,,98.60,,,percent of total billed charges,,,53.36,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.40,,,fee schedule,,,,,,,,
Cellavision Diff - Diff Type,10308205,CDM,0300,RC,85027,CPT,408,EAPG,,,,outpatient,facility,,,116.00,34.80,6.99,27.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,22.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,25.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Manual Diff - Diff Type,10308206,CDM,0300,RC,85027,CPT,,,,,,outpatient,facility,,,116.00,34.80,6.15,98.60,,27.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.34,,,fee schedule,,,20.53,,,fee schedule,,,13.49,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.39,,,fee schedule,,,6.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.47,,,fee schedule,,,14.62,,,fee schedule,,,,,,,,,6.34,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.20,,,fee schedule,,,87.0,,,percent of total billed charges,,,6.34,,,fee schedule,,,6.15,,,fee schedule,,,6.47,,,fee schedule,,,9.92,,,fee schedule,,,6.34,,,fee schedule,,,87.0,,,percent of total billed charges,,,,,,,,,6.47,,,fee schedule,,,,,,,,,98.60,,,percent of total billed charges,,,53.36,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.40,,,fee schedule,,,,,,,,
Manual Diff - Diff Type,10308206,CDM,0300,RC,85027,CPT,408,EAPG,,,,outpatient,facility,,,116.00,34.80,6.99,27.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,22.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,25.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Stool Pathogen Panel (PCR),10308220,CDM,0300,RC,87506,CPT,,,,,,outpatient,facility,,,576.00,172.80,249.84,594.36,,576.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,257.73,,,fee schedule,,,576.0,,,fee schedule,,,548.47,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,544.39,,,fee schedule,,,249.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",262.88,,,fee schedule,,,594.36,,,fee schedule,,,,,,,,,257.73,,,fee schedule,,,,,,,,,338.28,,,fee schedule,,,536.5,,,fee schedule,,,432.0,,,percent of total billed charges,,,257.73,,,fee schedule,,,249.84,,,fee schedule,,,262.88,,,fee schedule,,,397.83,,,fee schedule,,,257.73,,,fee schedule,,,432.0,,,percent of total billed charges,,,,,,,,,262.88,,,fee schedule,,,,,,,,,489.60,,,percent of total billed charges,,,264.96,,,percent of total billed charges,,,,,,,,,289.29,,,fee schedule,,,257.73,,,fee schedule,,,,,,,,,255.10,,,fee schedule,,,257.73,,,fee schedule,,,,,,,,,260.31,,,fee schedule,,,,,,,,
Stool Pathogen Panel (PCR),10308220,CDM,0300,RC,87506,CPT,388,EAPG,,,,outpatient,facility,,,576.00,172.80,202.12,322.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,273.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,202.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,222.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW COMP FIXOS HDLS 4X40MM,10310129,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FIXOS HDLS 4X40MM,10310129,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS COMP 7X70MM X_658370 X_STRYKER ORTHOPAE,10310130,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS COMP 7X70MM X_658370 X_STRYKER ORTHOPAE,10310130,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
REAMER CS CANN FIXIOS LG 7MM,10310131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2290.00,687.00,888.52,1946.5,,,,,,,,,,,,,,,,,,,,888.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,973.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1717.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1145.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1946.5,,,percent of total billed charges,,,1030.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REAMER CS CANN FIXIOS LG 7MM,10310131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2290.00,687.00,973.25,1946.5,,,,,,,,,,,,,service not payable,,,,,,,1155.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,973.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1717.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1145.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1717.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1946.5,,,percent of total billed charges,,,1053.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EASYCLIP EZ20-16-16 X_STRYKER ORTHOPAEDICS,10310132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3655.00,1096.50,1418.14,3106.75,,,,,,,,,,,,,,,,,,,,1418.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2741.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3106.75,,,percent of total billed charges,,,1644.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EASYCLIP EZ20-16-16 X_STRYKER ORTHOPAEDICS,10310132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3655.00,1096.50,1553.38,3106.75,,,,,,,,,,,,,service not payable,,,,,,,1843.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1553.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2741.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2741.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3106.75,,,percent of total billed charges,,,1681.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX HUM R 13H 3.5X216MM X_7180-1313 X_SMITH,10310133,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4301.00,1290.30,1668.79,3655.85,,,,,,,,,,,,,,,,,,,,1668.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3225.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2150.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3655.85,,,percent of total billed charges,,,1935.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX HUM R 13H 3.5X216MM X_7180-1313 X_SMITH,10310133,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4301.00,1290.30,1827.92,3655.85,,,,,,,,,,,,,service not payable,,,,,,,2169.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1827.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3225.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2150.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3225.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3655.85,,,percent of total billed charges,,,1978.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 8/7MMX26CM X_71770826 X_SMITH NEPHEW,10310134,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4291.00,1287.30,1664.91,3647.35,,,,,,,,,,,,,,,,,,,,1664.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1823.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3218.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2145.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3647.35,,,percent of total billed charges,,,1930.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 8/7MMX26CM X_71770826 X_SMITH NEPHEW,10310134,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4291.00,1287.30,1823.68,3647.35,,,,,,,,,,,,,service not payable,,,,,,,2164.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1823.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3218.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2145.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3218.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3647.35,,,percent of total billed charges,,,1973.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR CRUCIATE SM 15MM X_71204508 X_SMI,10310136,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7934.00,2380.20,3078.39,6743.90,,3887.66,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3332.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3078.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3371.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6743.90,,,percent of total billed charges,,,3570.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR CRUCIATE SM 15MM X_71204508 X_SMI,10310136,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7934.00,2380.20,3332.28,6743.90,,3887.66,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3332.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4001.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3371.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6743.90,,,percent of total billed charges,,,3649.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON KIT INFLATABLE 13G 10MM X_1021-310-000 X_S,10310140,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,2735.27,,,percent of total billed charges,,,,,,,,service not payable,2159.89,,,percent of total billed charges,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,2876.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2876.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX20MM X_BD-P30020ER X_TERU,10310141,CDM,0278,RC,C1725,HCPCS,,,,,,inpatient,facility,,,1974.00,592.20,765.91,1677.90,,,,,,,,,,,,,,,,,,,,765.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,838.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,987.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1677.90,,,percent of total billed charges,,,888.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PTA BALLOON 200CM 6F 3MMX20MM X_BD-P30020ER X_TERU,10310141,CDM,0278,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,,,,,,,,,,,,service not payable,,,,,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6FR 3MMX40MM,10310142,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX60MM X_BD-P30060ER X_TERU,10310143,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX80MM X_BD-P30080ER X_TERU,10310144,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX100MM,10310145,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX120MM X_BD-P30120ER X_TER,10310146,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX150MM,10310147,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 3MMX200MM,10310148,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX20MM X_BD-P40020ER X_TERU,10310149,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX40MM,10310150,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX60MM X_BD-P40060ER X_TERU,10310151,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX80MM X_BD-P40080ER X_TERU,10310152,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX100MM,10310153,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX120MM X_BD-P40120ER X_TER,10310154,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX150MM,10310155,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 4MMX200MM,10310156,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX20MM X_BD-P50020ER X_TERU,10310157,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX40MM,10310158,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX60MM X_BD-P50060ER X_TERU,10310159,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX80MM X_BD-P50080ER X_TERU,10310160,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX100MM,10310161,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX120MM X_BD-P50120ER X_TER,10310162,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX150MM,10310163,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 5MMX200MM,10310164,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX20MM X_BD-P60020ER X_TERU,10310165,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX40MM,10310166,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX60MM X_BD-P60060ER X_TERU,10310167,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX80MM X_BD-P60080ER X_TERU,10310168,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX100MM,10310169,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX120MM X_BD-P60120ER X_TER,10310170,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX150MM,10310171,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 6MMX200MM,10310172,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX20MM X_BD-P70020ER X_TERU,10310173,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX40MM,10310174,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX60MM X_BD-P70060ER X_TERU,10310175,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX80MM X_BD-P70080ER X_TERU,10310176,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX100MM,10310177,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX120MM X_BD-P70120ER X_TER,10310178,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX150MM,10310179,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 7MMX200MM X_BD-P70200ER X_TER,10310180,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 8MMX20MM X_BD-P80020ER X_TERU,10310181,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 8MMX40MM,10310182,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 8MMX60MM,10310183,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PTA BALLOON 200CM 6F 8MMX80MM,10310184,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC STD 350CM STR X_GR3536 X_TERUMO M,10310185,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2020.00,606.00,858.5,1717.0,,1248.36,,,percent of total billed charges,,,,,,,,service not payable,985.76,,,percent of total billed charges,,,1018.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,858.5,,,percent of total billed charges,,,,,,,,,1515.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1010.0,,,percent of total billed charges,,,,,,,,service not payable,1515.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1717.0,,,percent of total billed charges,,,929.20,,,percent of total billed charges,,,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC STD 350CM 45D X_GR3535 X_TERUMO M,10310186,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2020.00,606.00,858.5,1717.0,,1248.36,,,percent of total billed charges,,,,,,,,service not payable,985.76,,,percent of total billed charges,,,1018.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,858.5,,,percent of total billed charges,,,,,,,,,1515.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1010.0,,,percent of total billed charges,,,,,,,,service not payable,1515.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1717.0,,,percent of total billed charges,,,929.20,,,percent of total billed charges,,,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 350CM 1.5MM J X_GR3533 X_TERUMO M,10310187,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2020.00,606.00,858.5,1717.0,,1248.36,,,percent of total billed charges,,,,,,,,service not payable,985.76,,,percent of total billed charges,,,1018.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,858.5,,,percent of total billed charges,,,,,,,,,1515.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1010.0,,,percent of total billed charges,,,,,,,,service not payable,1515.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1717.0,,,percent of total billed charges,,,929.20,,,percent of total billed charges,,,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 350CM 3MM J X_GR3534 X_TERUMO MED,10310188,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2020.00,606.00,858.5,1717.0,,1248.36,,,percent of total billed charges,,,,,,,,service not payable,985.76,,,percent of total billed charges,,,1018.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,858.5,,,percent of total billed charges,,,,,,,,,1515.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1010.0,,,percent of total billed charges,,,,,,,,service not payable,1515.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1717.0,,,percent of total billed charges,,,929.20,,,percent of total billed charges,,,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1313.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 400CM STR X_GR3541 X_TERUMO MEDIC,10310189,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 400CM 45D X_GR3540 X_TERUMO MEDIC,10310190,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 400CM 1.5MM J X_GR3539 X_TERUMO M,10310191,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 400CM 3MM J X_GR3538 X_TERUMO MED,10310192,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM STR X_GR3546 X_TERUMO MEDIC,10310193,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM 45D X_GR3543 X_TERUMO MEDIC,10310194,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM 1.5MM J X_GR3544 X_TERUMO M,10310195,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM 3MM J X_GR3545 X_TERUMO MED,10310196,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 350CM STR X_GS3536 X_TERUMO MEDIC,10310197,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2276.00,682.80,967.30,1934.60,,1406.57,,,percent of total billed charges,,,,,,,,service not payable,1110.69,,,percent of total billed charges,,,1148.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,967.30,,,percent of total billed charges,,,,,,,,,1707.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1138.0,,,percent of total billed charges,,,,,,,,service not payable,1707.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1934.60,,,percent of total billed charges,,,1046.96,,,percent of total billed charges,,,,,,,,,1479.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1479.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 350CM 45D X_GS3535 X_TERUMO MEDIC,10310198,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2276.00,682.80,967.30,1934.60,,1406.57,,,percent of total billed charges,,,,,,,,service not payable,1110.69,,,percent of total billed charges,,,1148.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,967.30,,,percent of total billed charges,,,,,,,,,1707.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1138.0,,,percent of total billed charges,,,,,,,,service not payable,1707.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1934.60,,,percent of total billed charges,,,1046.96,,,percent of total billed charges,,,,,,,,,1479.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1479.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 350CM 45D X_GS3533 X_TERUMO MEDIC,10310199,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2276.00,682.80,967.30,1934.60,,1406.57,,,percent of total billed charges,,,,,,,,service not payable,1110.69,,,percent of total billed charges,,,1148.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,967.30,,,percent of total billed charges,,,,,,,,,1707.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1138.0,,,percent of total billed charges,,,,,,,,service not payable,1707.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1934.60,,,percent of total billed charges,,,1046.96,,,percent of total billed charges,,,,,,,,,1479.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1479.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPHILIC WIRE 400CM STR,10310200,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPHILIC WIRE 400CM 45D,10310201,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 400CM 1.5MM X_GS3539 X_TERUMO MED,10310202,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM STR X_GS3546 X_TERUMO MEDIC,10310203,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2341.00,702.30,994.92,1989.85,,1446.74,,,percent of total billed charges,,,,,,,,service not payable,1142.41,,,percent of total billed charges,,,1180.8,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.92,,,percent of total billed charges,,,,,,,,,1755.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1170.5,,,percent of total billed charges,,,,,,,,service not payable,1755.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1989.85,,,percent of total billed charges,,,1076.86,,,percent of total billed charges,,,,,,,,,1521.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1521.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM 45D X_GS3543 X_TERUMO MEDIC,10310204,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2341.00,702.30,994.92,1989.85,,1446.74,,,percent of total billed charges,,,,,,,,service not payable,1142.41,,,percent of total billed charges,,,1180.8,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.92,,,percent of total billed charges,,,,,,,,,1755.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1170.5,,,percent of total billed charges,,,,,,,,service not payable,1755.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1989.85,,,percent of total billed charges,,,1076.86,,,percent of total billed charges,,,,,,,,,1521.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1521.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE HYDROPHILIC 450CM 1.5MM J X_GS3544 X_TERUMO M,10310205,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2341.00,702.30,994.92,1989.85,,1446.74,,,percent of total billed charges,,,,,,,,service not payable,1142.41,,,percent of total billed charges,,,1180.8,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.92,,,percent of total billed charges,,,,,,,,,1755.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1170.5,,,percent of total billed charges,,,,,,,,service not payable,1755.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1989.85,,,percent of total billed charges,,,1076.86,,,percent of total billed charges,,,,,,,,,1521.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1521.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 4MM,10310863,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 4MM,10310863,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH SURGIMEND 4.0 20X30 X_606-400-017 X_INTEGRA L,10310864,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,24915.00,7474.50,9667.02,21177.75,,12208.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10464.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9667.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10588.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18686.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12457.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21177.75,,,percent of total billed charges,,,11211.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH SURGIMEND 4.0 20X30 X_606-400-017 X_INTEGRA L,10310864,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,24915.00,7474.50,10464.30,21177.75,,12208.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10464.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12567.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10588.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18686.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12457.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18686.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21177.75,,,percent of total billed charges,,,11460.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10311227,CDM,0320,RC,75705,CPT,,,,,,outpatient,facility,,,13728.00,4118.40,272.77,11668.80,,365.56,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,272.77,,,fee schedule,,,6924.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5834.40,,,percent of total billed charges,,,,,,,,,10296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6864.0,,,percent of total billed charges,,,,,,,,,10296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11668.80,,,percent of total billed charges,,,6314.88,,,percent of total billed charges,,,,,,,,,11519.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10311227,CDM,0320,RC,75705,CPT,05184,APC,,,,outpatient,facility,,,13728.00,4118.40,4972.31,11906.09,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10905.13,,,fee schedule,,,4972.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5287.57,,,fee schedule,,,11906.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10747.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,4972.31,,,fee schedule,,,5287.57,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,4972.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5287.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,5235.52,,,fee schedule,,,,,,,,
SP Exam,10311227,CDM,0320,RC,75705,CPT,280,EAPG,,,,outpatient,facility,,,13728.00,4118.40,6430.47,16406.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16406.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13945.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7392.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,8131.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BASE PLT REV 25MM PLOT LNG,10311265,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5848.00,1754.40,2269.02,4970.80,,2865.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2456.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2269.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2485.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4386.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2924.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4970.80,,,percent of total billed charges,,,2631.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE PLT REV 25MM PLOT LNG,10311265,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5848.00,1754.40,2456.16,4970.80,,2865.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2456.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2949.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2485.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4386.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2924.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4386.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4970.80,,,percent of total billed charges,,,2690.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SET SALIVARY DUCT BAL 2.0,10311266,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,1336.73,,,percent of total billed charges,,,,,,,,service not payable,1055.54,,,percent of total billed charges,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,1405.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1405.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST TIBIAL 5H X_72820805 X_SMITH NEPHEW,10311267,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2077.00,623.10,805.88,1765.45,,,,,,,,,,,,,,,,,,,,805.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,882.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1765.45,,,percent of total billed charges,,,934.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST TIBIAL 5H X_72820805 X_SMITH NEPHEW,10311267,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2077.00,623.10,882.73,1765.45,,,,,,,,,,,,,service not payable,,,,,,,1047.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,882.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1765.45,,,percent of total billed charges,,,955.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR BIORAPTOR KNOTLESS X_72202403 X_SMITH NEPHE,10311268,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1791.00,537.30,694.91,1522.35,,,,,,,,,,,,,,,,,,,,694.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1343.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,895.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.35,,,percent of total billed charges,,,805.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR BIORAPTOR KNOTLESS X_72202403 X_SMITH NEPHE,10311268,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1791.00,537.30,761.17,1522.35,,,,,,,,,,,,,service not payable,,,,,,,903.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,761.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1343.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,895.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1343.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1522.35,,,percent of total billed charges,,,823.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ASSURITY SNGL IS-1,10311269,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,8753.00,2625.90,3396.16,7440.05,,4288.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.26,,,percent of total billed charges,,Paid in addition to inpatient services ,3396.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3720.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6564.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4376.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7440.05,,,percent of total billed charges,,,3938.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ASSURITY SNGL IS-1,10311269,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,8753.00,2625.90,3676.26,7440.05,,4288.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.26,,,percent of total billed charges,,Paid in addition to outpatient services ,4415.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3720.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6564.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4376.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6564.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7440.05,,,percent of total billed charges,,,4026.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
POSITIONING ECHO W VENTRA SYS,10311356,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2542.00,762.60,986.30,2160.70,,,,,,,,,,,,,,,,,,,,986.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1080.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1906.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1271.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.70,,,percent of total billed charges,,,1143.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POSITIONING ECHO W VENTRA SYS,10311356,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2542.00,762.60,1080.35,2160.70,,,,,,,,,,,,,service not payable,,,,,,,1282.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1080.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1906.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1271.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1906.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2160.70,,,percent of total billed charges,,,1169.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 18X60MM 11F 100CM,10311357,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4459.00,1337.70,1730.09,3790.15,,,,,,,,,,,,,,,,,,,,1730.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1895.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3344.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2229.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3790.15,,,percent of total billed charges,,,2006.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 18X60MM 11F 100CM,10311357,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4459.00,1337.70,1895.08,3790.15,,,,,,,,,,,,,service not payable,,,,,,,2249.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1895.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3344.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2229.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3344.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3790.15,,,percent of total billed charges,,,2051.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING VASC 10F 45CM,10311358,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,253.38,,,percent of total billed charges,,,,,,,,service not payable,200.08,,,percent of total billed charges,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,266.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER THERMOCOOL SMART TOUCH X_D134804 X_BIOSEN,10311359,CDM,0272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,13002.00,3900.60,5525.85,11051.70,,8035.24,,,percent of total billed charges,,,,,,,,service not payable,6344.98,,,percent of total billed charges,,,6558.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5525.85,,,percent of total billed charges,,,,,,,,,9751.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6501.0,,,percent of total billed charges,,,,,,,,service not payable,9751.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11051.70,,,percent of total billed charges,,,5980.92,,,percent of total billed charges,,,,,,,,,8451.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8451.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST CORT 4.5X66MM X_340666 X_STRYKER ORTHOPAE,10313442,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,148.00,44.40,57.42,125.8,,,,,,,,,,,,,,,,,,,,57.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,66.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST CORT 4.5X66MM X_340666 X_STRYKER ORTHOPAE,10313442,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,,,,,,,,,,,,service not payable,,,,,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT TI 4.5X70MM X_661770 X_STRYKER ORTHOPAE,10313444,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT TI 4.5X70MM X_661770 X_STRYKER ORTHOPAE,10313444,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP NERVE COLLAGEN 6MMX2.5CM,10313445,CDM,0278,RC,C9353,HCPCS,,,,,,inpatient,facility,,,5130.00,1539.00,1990.44,4360.5,,2513.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2154.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1990.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2180.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3847.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2565.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4360.5,,,percent of total billed charges,,,2308.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WRAP NERVE COLLAGEN 6MMX2.5CM,10313445,CDM,0278,RC,C9353,HCPCS,,,,,,outpatient,facility,,,5130.00,1539.00,2154.60,4360.5,,2513.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2154.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2587.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2180.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3847.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2565.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3847.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4360.5,,,percent of total billed charges,,,2359.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP NERVE COLLAGEN 6MMX2.5CM,10313445,CDM,0278,RC,C9353,HCPCS,455,EAPG,,,,outpatient,facility,,,5130.00,1539.00,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT IPSL LEG 28X14.5MMX14CM,10313448,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,25257.00,7577.10,9799.72,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9799.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21468.45,,,percent of total billed charges,,,11365.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT IPSL LEG 28X14.5MMX14CM,10313448,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,25257.00,7577.10,10607.94,21468.45,,12375.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10607.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12739.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10734.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18942.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12628.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18942.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21468.45,,,percent of total billed charges,,,11618.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON CATH 10-37MM 4X90CM,10313449,CDM,0278,RC,C2628,HCPCS,,,,,,inpatient,facility,,,2225.00,667.50,863.30,1891.25,,,,,,,,,,,,,,,,,,,,863.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1668.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1112.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1891.25,,,percent of total billed charges,,,1001.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON CATH 10-37MM 4X90CM,10313449,CDM,0278,RC,C2628,HCPCS,,,,,,outpatient,facility,,,2225.00,667.50,945.62,1891.25,,,,,,,,,,,,,service not payable,,,,,,,1122.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,945.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1668.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1112.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1668.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1891.25,,,percent of total billed charges,,,1023.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABIL 10MMX6X40CM,10313450,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,9372.00,2811.60,3636.34,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3636.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7966.20,,,percent of total billed charges,,,4217.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABIL 10MMX6X40CM,10313450,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,9372.00,2811.60,3936.24,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4727.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7966.20,,,percent of total billed charges,,,4311.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FIXED LK 4.75X40MM,10313451,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FIXED LK 4.75X40MM,10313451,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEXALOBE 2.7X18MM,10313452,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,662.00,198.60,256.86,562.70,,,,,,,,,,,,,,,,,,,,256.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.70,,,percent of total billed charges,,,297.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEXALOBE 2.7X18MM,10313452,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,662.00,198.60,281.35,562.70,,,,,,,,,,,,,service not payable,,,,,,,333.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,496.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,331.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,496.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,562.70,,,percent of total billed charges,,,304.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETABULAR 54MM X_71338666 X_SMITH NEPHEW,10313453,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3427.00,1028.10,1329.68,2912.95,,,,,,,,,,,,,,,,,,,,1329.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.95,,,percent of total billed charges,,,1542.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR 54MM X_71338666 X_SMITH NEPHEW,10313453,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3427.00,1028.10,1456.47,2912.95,,,,,,,,,,,,,service not payable,,,,,,,1728.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.95,,,percent of total billed charges,,,1576.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL 3X20CM X_RBY2C0320 X_PENUMBRA INC,10313718,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL EMBOL 3X20CM X_RBY2C0320 X_PENUMBRA INC,10313718,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEXALOBE 2.3X10MM X_3004-23010 X_ACUMED,10313720,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEXALOBE 2.3X10MM X_3004-23010 X_ACUMED,10313720,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEX TI 11X2.3STR,10313721,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEX TI 11X2.3STR,10313721,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEXALOBE 2.3X9MM X_3012-23009 X_ACUMED,10313722,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEXALOBE 2.3X9MM X_3012-23009 X_ACUMED,10313722,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1.3MM 6 HOLE X_7005-13006 X_ACUMED,10313723,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2196.00,658.80,852.05,1866.60,,,,,,,,,,,,,,,,,,,,852.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,933.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1647.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1866.60,,,percent of total billed charges,,,988.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1.3MM 6 HOLE X_7005-13006 X_ACUMED,10313723,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2196.00,658.80,933.30,1866.60,,,,,,,,,,,,,service not payable,,,,,,,1107.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,933.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1647.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1647.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1866.60,,,percent of total billed charges,,,1010.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CRANIO TI SI MANDIBLE,10313725,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,23166.00,6949.80,8988.41,19691.10,,11351.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9729.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8988.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9845.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17374.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11583.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19691.10,,,percent of total billed charges,,,10424.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CRANIO TI SI MANDIBLE,10313725,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,23166.00,6949.80,9729.72,19691.10,,11351.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9729.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11684.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9845.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17374.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11583.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17374.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19691.10,,,percent of total billed charges,,,10656.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6.5X130MM X_74820130 X_SMITH NEPHEW,10313727,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,939.00,281.70,364.33,798.15,,,,,,,,,,,,,,,,,,,,364.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,704.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,469.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,798.15,,,percent of total billed charges,,,422.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6.5X130MM X_74820130 X_SMITH NEPHEW,10313727,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,939.00,281.70,399.07,798.15,,,,,,,,,,,,,service not payable,,,,,,,473.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,399.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,704.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,469.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,704.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,798.15,,,percent of total billed charges,,,431.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 7X40X130,10313728,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING VASC 12F 45CM,10313729,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWVLK 4.75X24.5MM X_AR-2324BCM X_ARTHREX IN,10313835,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWVLK 4.75X24.5MM X_AR-2324BCM X_ARTHREX IN,10313835,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 4.0X30MM X_626830 X_STRYKER ORTHOPAEDICS,10313837,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1364.00,409.20,529.23,1159.40,,,,,,,,,,,,,,,,,,,,529.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,579.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1023.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1159.40,,,percent of total billed charges,,,613.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 4.0X30MM X_626830 X_STRYKER ORTHOPAEDICS,10313837,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1364.00,409.20,579.70,1159.40,,,,,,,,,,,,,service not payable,,,,,,,688.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,579.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1023.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1023.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1159.40,,,percent of total billed charges,,,627.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE EXPRESS 10 X 10 X 10MM,10313838,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5950.00,1785.00,2308.60,5057.5,,2915.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2499.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2308.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2528.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4462.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2975.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5057.5,,,percent of total billed charges,,,2677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE EXPRESS 10 X 10 X 10MM,10313838,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5950.00,1785.00,2499.0,5057.5,,2915.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2499.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3001.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2528.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4462.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2975.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4462.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5057.5,,,percent of total billed charges,,,2737.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 4X50MM X_IH4050 X_STRYKER ORTHOPAEDICS,10313839,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2938.00,881.40,1139.94,2497.30,,,,,,,,,,,,,,,,,,,,1139.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1248.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2203.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1469.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2497.30,,,percent of total billed charges,,,1322.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 4X50MM X_IH4050 X_STRYKER ORTHOPAEDICS,10313839,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2938.00,881.40,1248.65,2497.30,,,,,,,,,,,,,service not payable,,,,,,,1481.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1248.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2203.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1469.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2203.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2497.30,,,percent of total billed charges,,,1351.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 2.3X28MM X_50-330-28-09 X_KLS MARTIN L P,10313840,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,349.00,104.70,135.41,296.65,,,,,,,,,,,,,,,,,,,,135.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,157.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 2.3X28MM X_50-330-28-09 X_KLS MARTIN L P,10313840,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,349.00,104.70,148.32,296.65,,,,,,,,,,,,,service not payable,,,,,,,176.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,296.65,,,percent of total billed charges,,,160.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ingestion Challenge Test 120 min,10314033,CDM,0924,RC,95076,CPT,,,,,,outpatient,facility,,,1356.00,406.80,184.0,1152.60,,838.01,,,percent of total billed charges,,,,,,,,,661.73,,,percent of total billed charges,,,683.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.30,,,percent of total billed charges,,,,,,,,,1017.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,678.0,,,percent of total billed charges,,,,,,,,,1017.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1152.60,,,percent of total billed charges,,,623.76,,,percent of total billed charges,,,,,,,,,209.0,,,per diem,,,,,,,,,,,,,,,184.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Ingestion Challenge Test 120 min,10314033,CDM,0924,RC,95076,CPT,05723,APC,,,,outpatient,facility,,,1356.00,406.80,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
Ingestion Challenge Test 120 min,10314033,CDM,0924,RC,95076,CPT,130,EAPG,,,,outpatient,facility,,,1356.00,406.80,565.93,2256.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2256.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1917.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1178.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1296.48,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR BONE 1 X_2503-S X_SMITH NEPHEW,10314099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR BONE 1 X_2503-S X_SMITH NEPHEW,10314099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 9MMX32CM LT X_71649532 X_SMITH NEPHEW,10314100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10900.00,3270.00,4229.20,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4229.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9265.0,,,percent of total billed charges,,,4905.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 9MMX32CM LT X_71649532 X_SMITH NEPHEW,10314100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10900.00,3270.00,4578.0,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5497.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9265.0,,,percent of total billed charges,,,5014.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL 52X20MM X_5552-S-5220 X_STRYKER,10314101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3667.00,1100.10,1422.80,3116.95,,,,,,,,,,,,,,,,,,,,1422.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3116.95,,,percent of total billed charges,,,1650.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL 52X20MM X_5552-S-5220 X_STRYKER,10314101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3667.00,1100.10,1558.47,3116.95,,,,,,,,,,,,,service not payable,,,,,,,1849.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1558.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2750.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1833.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2750.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3116.95,,,percent of total billed charges,,,1686.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR ROD/ROD SM 7MM X_48230141 X_STRYKER,10314103,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR ROD/ROD SM 7MM X_48230141 X_STRYKER,10314103,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK TI ST FT 5.0X40MM,10314104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2120.00,636.00,822.56,1802.0,,,,,,,,,,,,,,,,,,,,822.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,901.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1590.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1060.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1802.0,,,percent of total billed charges,,,954.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK TI ST FT 5.0X40MM,10314104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2120.00,636.00,901.0,1802.0,,,,,,,,,,,,,service not payable,,,,,,,1069.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,901.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1590.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1060.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1590.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1802.0,,,percent of total billed charges,,,975.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB STBplus  SZ2.5 17.5MM,10314106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7364.00,2209.20,2857.23,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2857.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6259.40,,,percent of total billed charges,,,3313.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB STBplus  SZ2.5 17.5MM,10314106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7364.00,2209.20,3092.88,6259.40,,3608.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3714.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3129.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5523.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3682.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5523.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6259.40,,,percent of total billed charges,,,3387.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRA UL40 SHA 6F 110CM,10314110,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRA UL35 SHA 6F 110CM,10314111,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWIVELOCK 5.5X24.5MM X_AR-2323BCM X_ARTHREX,10314116,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWIVELOCK 5.5X24.5MM X_AR-2323BCM X_ARTHREX,10314116,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT ECHO 2 11.2CM,10314117,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2229.00,668.70,864.85,1894.65,,,,,,,,,,,,,,,,,,,,864.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,947.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1894.65,,,percent of total billed charges,,,1003.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT ECHO 2 11.2CM,10314117,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2229.00,668.70,947.32,1894.65,,,,,,,,,,,,,service not payable,,,,,,,1124.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,947.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1894.65,,,percent of total billed charges,,,1025.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 15X20CM,10314118,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 15X20CM,10314118,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 20CM CIRCLE X_5990020 X_CR BARD I,10314119,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4458.00,1337.40,1729.70,3789.30,,,,,,,,,,,,,,,,,,,,1729.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1894.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3789.30,,,percent of total billed charges,,,2006.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 20CM CIRCLE X_5990020 X_CR BARD I,10314119,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4458.00,1337.40,1894.65,3789.30,,,,,,,,,,,,,service not payable,,,,,,,2248.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1894.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3343.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3789.30,,,percent of total billed charges,,,2050.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 15X25CM X_5991525 X_CR BARD INC,10314120,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4458.00,1337.40,1729.70,3789.30,,,,,,,,,,,,,,,,,,,,1729.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1894.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3789.30,,,percent of total billed charges,,,2006.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 15X25CM X_5991525 X_CR BARD INC,10314120,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4458.00,1337.40,1894.65,3789.30,,,,,,,,,,,,,service not payable,,,,,,,2248.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1894.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3343.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3789.30,,,percent of total billed charges,,,2050.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 18X23CM,10314121,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 18X23CM,10314121,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 20X25CM,10314122,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,5705.00,1711.50,2213.54,4849.25,,2795.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2396.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2213.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2424.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4849.25,,,percent of total billed charges,,,2567.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 20X25CM,10314122,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,5705.00,1711.50,2396.10,4849.25,,2795.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2396.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2877.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2424.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4278.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4278.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4849.25,,,percent of total billed charges,,,2624.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRALIGHT 25X33CM,10314123,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,7278.00,2183.40,2823.86,6186.30,,3566.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3056.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2823.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3093.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5458.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3639.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6186.30,,,percent of total billed charges,,,3275.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRALIGHT 25X33CM,10314123,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,7278.00,2183.40,3056.76,6186.30,,3566.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3056.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3671.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3093.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5458.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3639.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5458.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6186.30,,,percent of total billed charges,,,3347.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
METH VENTRALIGHT 30X35CM X_5993035 X_CR BARD INC,10314124,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,7540.00,2262.00,2925.52,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2925.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,,3393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METH VENTRALIGHT 30X35CM X_5993035 X_CR BARD INC,10314124,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,7540.00,2262.00,3166.80,6409.0,,3694.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3166.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3803.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5655.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5655.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,,3468.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOC AKREOS AO 14.5 X_AO60P-14.5 X_BAUSCH AND,10314129,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 14.5 X_AO60P-14.5 X_BAUSCH AND,10314129,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
"GWIRE LUGE STR TIP .014 300CM""""",10314130,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,220.01,,,percent of total billed charges,,,,,,,,service not payable,173.73,,,percent of total billed charges,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,231.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,231.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID 15D MEDIUM AUG RIGHT,10314132,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12248.00,3674.40,4752.22,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4752.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10410.80,,,percent of total billed charges,,,5511.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID 15D MEDIUM AUG RIGHT,10314132,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12248.00,3674.40,5144.16,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6177.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10410.80,,,percent of total billed charges,,,5634.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL 52X19MM X_DWF252 X_TORNIER INC,10314133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12473.00,3741.90,4839.52,10602.05,,6111.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5238.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4839.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5301.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9354.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6236.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10602.05,,,percent of total billed charges,,,5612.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL 52X19MM X_DWF252 X_TORNIER INC,10314133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12473.00,3741.90,5238.66,10602.05,,6111.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5238.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6291.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5301.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9354.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6236.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9354.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10602.05,,,percent of total billed charges,,,5737.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM MOD DXTEND SZ 1 8.0MM,10314134,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM MOD DXTEND SZ 1 8.0MM,10314134,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM DXTEND CTA 48X21MM,10314135,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8953.00,2685.90,3473.76,7610.05,,4386.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3760.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3473.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3805.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6714.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7610.05,,,percent of total billed charges,,,4028.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM DXTEND CTA 48X21MM,10314135,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8953.00,2685.90,3760.26,7610.05,,4386.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3760.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4515.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3805.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6714.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6714.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7610.05,,,percent of total billed charges,,,4118.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Removal fecal impaction or foreign body under anes,10314396,CDM,0450,RC,45915,CPT,,,,,,outpatient,facility,,,2943.00,882.90,774.0,2501.55,,1818.77,,,percent of total billed charges,,,,,,,,,1436.18,,,percent of total billed charges,,,1484.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2207.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2207.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.55,,,percent of total billed charges,,,1353.78,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal fecal impaction or foreign body under anes,10314396,CDM,0450,RC,45915,CPT,05312,APC,,,,outpatient,facility,,,2943.00,882.90,542.27,2596.92,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,2378.60,,,fee schedule,,,542.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1153.3,,,fee schedule,,,2596.92,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,2344.12,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,542.27,,,fee schedule,,,1153.3,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,542.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1153.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,1141.95,,,fee schedule,,,,,,,,
Removal fecal impaction or foreign body under anes,10314396,CDM,0450,RC,45915,CPT,141,EAPG,,,,outpatient,facility,,,2943.00,882.90,2092.24,5987.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5987.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5089.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3000.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3300.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CAGE POST LUM 6D 13X28X9MM X_48954136 X_STRYKER SP,10314516,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 6D 13X28X9MM X_48954136 X_STRYKER SP,10314516,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ONE-THRD TUB 2HX23MM X_626672 X_STRYKER ORTH,10314517,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2348.00,704.40,911.02,1995.8,,,,,,,,,,,,,,,,,,,,911.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1761.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1174.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995.8,,,percent of total billed charges,,,1056.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ONE-THRD TUB 2HX23MM X_626672 X_STRYKER ORTH,10314517,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2348.00,704.40,997.90,1995.8,,,,,,,,,,,,,service not payable,,,,,,,1184.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,997.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1761.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1174.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1761.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1995.8,,,percent of total billed charges,,,1080.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ONE-THRD TUB 7HX83MM X_626677 X_STRYKER ORTH,10314518,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2348.00,704.40,911.02,1995.8,,,,,,,,,,,,,,,,,,,,911.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1761.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1174.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995.8,,,percent of total billed charges,,,1056.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ONE-THRD TUB 7HX83MM X_626677 X_STRYKER ORTH,10314518,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2348.00,704.40,997.90,1995.8,,,,,,,,,,,,,service not payable,,,,,,,1184.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,997.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1761.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1174.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1761.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1995.8,,,percent of total billed charges,,,1080.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FT 3.5X8MM X_657408 X_STRYKER ORTHOPAED,10314519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FT 3.5X8MM X_657408 X_STRYKER ORTHOPAED,10314519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T10 FT 3.5X48MM,10314520,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,679.00,203.70,263.45,577.15,,,,,,,,,,,,,,,,,,,,263.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,509.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,339.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.15,,,percent of total billed charges,,,305.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T10 FT 3.5X48MM,10314520,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,679.00,203.70,288.57,577.15,,,,,,,,,,,,,service not payable,,,,,,,342.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,288.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,509.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,339.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,509.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,577.15,,,percent of total billed charges,,,312.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON EXPANDABLE ENDO 7X79MM X_BXA077902A X_GORE,10314521,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4973.77,9947.55,,7232.45,,,percent of total billed charges,,,,,,,,service not payable,5711.06,,,percent of total billed charges,,,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,7606.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7606.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM PROX ZTT B20 SML,10314522,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM PROX ZTT B20 SML,10314522,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRD 20X15X165 36NK,10314524,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRD 20X15X165 36NK,10314524,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IV SINGLE LUMEN 7F 6IN,10314528,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,396.00,118.80,168.30,336.60,,244.73,,,percent of total billed charges,,,,,,,,service not payable,193.25,,,percent of total billed charges,,,199.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,168.30,,,percent of total billed charges,,,,,,,,,297.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,198.0,,,percent of total billed charges,,,,,,,,service not payable,297.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,336.60,,,percent of total billed charges,,,182.16,,,percent of total billed charges,,,,,,,,,257.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,257.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRIAL GII DEEP FLEX ISRT 11MM X_71430443 X_SMITH N,10314532,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,793.00,237.90,307.68,674.05,,,,,,,,,,,,,,,,,,,,307.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,356.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAL GII DEEP FLEX ISRT 11MM X_71430443 X_SMITH N,10314532,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,,,,,,,,,,,,service not payable,,,,,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE SZ GII SHIM 1 DCF X_71441164 X_SMITH NEPHEW,10314533,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1983.00,594.90,769.40,1685.55,,,,,,,,,,,,,,,,,,,,769.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,842.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1685.55,,,percent of total billed charges,,,892.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE SZ GII SHIM 1 DCF X_71441164 X_SMITH NEPHEW,10314533,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1983.00,594.90,842.77,1685.55,,,,,,,,,,,,,service not payable,,,,,,,1000.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,842.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1685.55,,,percent of total billed charges,,,912.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 8F BLUE X_PLS-1008 X_MERIT MEDIC,10314534,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,186.00,55.80,79.05,158.10,,114.95,,,percent of total billed charges,,,,,,,,service not payable,90.77,,,percent of total billed charges,,,93.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,79.05,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,93.0,,,percent of total billed charges,,,,,,,,service not payable,139.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,,85.56,,,percent of total billed charges,,,,,,,,,120.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,120.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS TAG X_TGU343410 X_W L GORE,10314535,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,37310.00,11193.00,14476.28,31713.5,,18281.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15670.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14476.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15856.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27982.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18655.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31713.5,,,percent of total billed charges,,,16789.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS TAG X_TGU343410 X_W L GORE,10314535,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,37310.00,11193.00,15670.20,31713.5,,18281.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15670.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18819.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15856.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27982.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18655.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27982.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31713.5,,,percent of total billed charges,,,17162.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 22F 33CM,10314537,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2640.00,792.00,1122.0,2244.0,,1631.52,,,percent of total billed charges,,,,,,,,service not payable,1288.32,,,percent of total billed charges,,,1331.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,,1980.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1320.0,,,percent of total billed charges,,,,,,,,service not payable,1980.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2244.0,,,percent of total billed charges,,,1214.40,,,percent of total billed charges,,,,,,,,,1716.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1716.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 6.0,10314538,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 6.0,10314538,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.4 X 14MM,10314730,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1714.00,514.20,665.03,1456.90,,,,,,,,,,,,,,,,,,,,665.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1285.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,857.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.90,,,percent of total billed charges,,,771.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.4 X 14MM,10314730,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1714.00,514.20,728.45,1456.90,,,,,,,,,,,,,service not payable,,,,,,,864.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,728.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1285.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,857.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1285.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1456.90,,,percent of total billed charges,,,788.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE JR4 6F 110CM,10314733,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE MPB1 6F 110CM X_LA6MB1A X_MEDTRONIC USA,10314734,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE MPB2 6F 110CM X_LA6MB2A X_MEDTRONIC USA,10314735,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE GRAFIX 7.5X15CM X_PS24075 X_OSIRIS TH,10314736,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,24915.00,7474.50,10588.88,21177.75,,15397.47,,,percent of total billed charges,,,,,,,,service not payable,12158.52,,,percent of total billed charges,,,12567.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10588.88,,,percent of total billed charges,,,,,,,,,18686.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12457.5,,,percent of total billed charges,,,,,,,,service not payable,18686.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21177.75,,,percent of total billed charges,,,11460.9,,,percent of total billed charges,,,,,,,,,16194.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,16194.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE GRAFIX 7.5X15CM X_PS24075 X_OSIRIS TH,10314736,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,24915.00,7474.50,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFIX PL PRIME 16MM DISC,10314737,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,1336.73,,,percent of total billed charges,,,,,,,,service not payable,1055.54,,,percent of total billed charges,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,1405.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1405.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFIX PL PRIME 16MM DISC,10314737,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,2163.00,648.90,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT GRAFIX PL PRIME 1.5X2CM X_PS13015 X_OSIRIS T,10314738,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,3654.00,1096.20,1552.95,3105.90,,2258.17,,,percent of total billed charges,,,,,,,,service not payable,1783.15,,,percent of total billed charges,,,1843.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1552.95,,,percent of total billed charges,,,,,,,,,2740.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1827.0,,,percent of total billed charges,,,,,,,,service not payable,2740.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3105.90,,,percent of total billed charges,,,1680.84,,,percent of total billed charges,,,,,,,,,2375.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2375.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT GRAFIX PL PRIME 1.5X2CM X_PS13015 X_OSIRIS T,10314738,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,3654.00,1096.20,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT GRAFIX PL PRIME 3X3CM X_PS13033 X_OSIRIS THE,10314740,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,2533.18,,,percent of total billed charges,,,,,,,,service not payable,2000.31,,,percent of total billed charges,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2664.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT GRAFIX PL PRIME 3X3CM X_PS13033 X_OSIRIS THE,10314740,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,4099.00,1229.70,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFIX PL PRIME 3 X 4CM,10314741,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,2735.27,,,percent of total billed charges,,,,,,,,service not payable,2159.89,,,percent of total billed charges,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,2876.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2876.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFIX PL PRIME 3 X 4CM,10314741,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,4426.00,1327.80,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT GRAFIX PL PRIME 5X5CM X_PS13055 X_OSIRIS THE,10314742,CDM,0279,RC,Q4133,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4179.88,8359.75,,6078.03,,,percent of total billed charges,,,,,,,,service not payable,4799.48,,,percent of total billed charges,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT GRAFIX PL PRIME 5X5CM X_PS13055 X_OSIRIS THE,10314742,CDM,0279,RC,Q4133,HCPCS,2010,EAPG,,,,outpatient,facility,,,9835.00,2950.50,115.75,136.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,115.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,136.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT STRAVIX 3X6CM,10314743,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,10983.00,3294.90,4261.40,9335.55,,5381.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4612.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4261.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4667.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8237.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5491.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9335.55,,,percent of total billed charges,,,4942.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STRAVIX 3X6CM,10314743,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,10983.00,3294.90,4612.86,9335.55,,5381.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4612.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5539.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4667.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8237.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5491.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8237.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9335.55,,,percent of total billed charges,,,5052.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM MINI 13X83MM,10314744,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM MINI 13X83MM,10314744,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE ALLODERM RTU PERF THK,10315056,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,14130.00,4239.00,5482.44,12010.5,,6923.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5934.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5482.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6005.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10597.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7065.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12010.5,,,percent of total billed charges,,,6358.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE ALLODERM RTU PERF THK,10315056,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,14130.00,4239.00,5934.60,14130.0,,6923.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5934.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7127.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6005.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10597.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7065.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10597.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12010.5,,,percent of total billed charges,,,6499.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,14130.0,,,percent of total billed charges,,,,,,,,service not payable,14130.0,,,percent of total billed charges,,
TISSUE ALLODERM RTU PERF THK,10315056,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,14130.00,4239.00,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROMATRIX 4X2.5CM X_CNC4025 X_COLLAGEN MATRIX IN,10315057,CDM,0278,RC,C9355,HCPCS,,,,,,inpatient,facility,,,4370.00,1311.00,1695.56,3714.5,,,,,,,,,,,,,,,,,,,,1695.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3277.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2185.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3714.5,,,percent of total billed charges,,,1966.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROMATRIX 4X2.5CM X_CNC4025 X_COLLAGEN MATRIX IN,10315057,CDM,0278,RC,C9355,HCPCS,,,,,,outpatient,facility,,,4370.00,1311.00,1857.25,3714.5,,,,,,,,,,,,,service not payable,,,,,,,2204.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1857.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3277.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2185.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3277.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3714.5,,,percent of total billed charges,,,2010.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROMATRIX 4X2.5CM X_CNC4025 X_COLLAGEN MATRIX IN,10315057,CDM,0278,RC,C9355,HCPCS,455,EAPG,,,,outpatient,facility,,,4370.00,1311.00,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH KIT INDIGO XTORQ 8F 115CM,10315058,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 4.5X22MM X_AR-8545-22 X_ARTHREX INC,10315059,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 4.5X22MM X_AR-8545-22 X_ARTHREX INC,10315059,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT FUSE OTOLOGIC PROCEM,10315060,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2153.00,645.90,835.36,1830.05,,,,,,,,,,,,,,,,,,,,835.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1614.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1076.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1830.05,,,percent of total billed charges,,,968.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT FUSE OTOLOGIC PROCEM,10315060,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2153.00,645.90,915.02,1830.05,,,,,,,,,,,,,service not payable,,,,,,,1085.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,915.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1614.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1076.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1614.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1830.05,,,percent of total billed charges,,,990.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
US Exam,10315091,CDM,0761,RC,10005,CPT,,,,,,outpatient,facility,,,1817.00,545.10,118.0,1544.45,,1122.91,,,percent of total billed charges,,,,,,,,,886.70,,,percent of total billed charges,,,916.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.23,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,908.5,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,,835.82,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
US Exam,10315091,CDM,0761,RC,10005,CPT,05071,APC,,,,outpatient,facility,,,1817.00,545.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
US Exam,10315091,CDM,0761,RC,10005,CPT,2,EAPG,,,,outpatient,facility,,,1817.00,545.10,933.72,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10315109,CDM,0761,RC,10005,CPT,,,,,,outpatient,facility,,,1817.00,545.10,118.0,1544.45,,1122.91,,,percent of total billed charges,,,,,,,,,886.70,,,percent of total billed charges,,,916.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.23,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,908.5,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,,835.82,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10315109,CDM,0761,RC,10005,CPT,05071,APC,,,,outpatient,facility,,,1817.00,545.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
SP Exam,10315109,CDM,0761,RC,10005,CPT,2,EAPG,,,,outpatient,facility,,,1817.00,545.10,933.72,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10315111,CDM,0761,RC,10007,CPT,,,,,,outpatient,facility,,,1817.00,545.10,118.0,1544.45,,1122.91,,,percent of total billed charges,,,,,,,,,886.70,,,percent of total billed charges,,,916.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.23,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,908.5,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,,835.82,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10315111,CDM,0761,RC,10007,CPT,05071,APC,,,,outpatient,facility,,,1817.00,545.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
SP Exam,10315111,CDM,0761,RC,10007,CPT,2,EAPG,,,,outpatient,facility,,,1817.00,545.10,933.72,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COMPONENT VENOUS OUTFLOW 5MMX40CM W/MRKR X_HERO100,10315130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT VENOUS OUTFLOW 5MMX40CM W/MRKR X_HERO100,10315130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 11X23X6DEG 11MM X_48951116 X_STRYKER,10315131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 11X23X6DEG 11MM X_48951116 X_STRYKER,10315131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE TRI ASY PAT 38X11M,10315133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE TRI ASY PAT 38X11M,10315133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NATURAL 10MMX20CM,10315135,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6130.00,1839.00,2378.44,5210.5,,3003.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2574.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2378.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2605.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4597.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3065.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5210.5,,,percent of total billed charges,,,2758.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NATURAL 10MMX20CM,10315135,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6130.00,1839.00,2574.60,5210.5,,3003.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2574.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3091.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2605.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4597.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3065.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4597.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5210.5,,,percent of total billed charges,,,2819.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT ANG 6.0X80MM,10315137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,992.00,297.60,384.90,843.20,,,,,,,,,,,,,,,,,,,,384.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,744.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,496.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,843.20,,,percent of total billed charges,,,446.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT ANG 6.0X80MM,10315137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,992.00,297.60,421.60,843.20,,,,,,,,,,,,,service not payable,,,,,,,500.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,421.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,744.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,496.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,744.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,843.20,,,percent of total billed charges,,,456.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT ANG 6.0X55MM,10315138,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,992.00,297.60,384.90,843.20,,,,,,,,,,,,,,,,,,,,384.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,744.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,496.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,843.20,,,percent of total billed charges,,,446.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT ANG 6.0X55MM,10315138,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,992.00,297.60,421.60,843.20,,,,,,,,,,,,,service not payable,,,,,,,500.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,421.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,744.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,496.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,744.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,843.20,,,percent of total billed charges,,,456.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CT Exam,10315190,CDM,0761,RC,10009,CPT,,,,,,outpatient,facility,,,1817.00,545.10,118.0,1544.45,,1122.91,,,percent of total billed charges,,,,,,,,,886.70,,,percent of total billed charges,,,916.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.23,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,908.5,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,,835.82,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10315190,CDM,0761,RC,10009,CPT,05071,APC,,,,outpatient,facility,,,1817.00,545.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
CT Exam,10315190,CDM,0761,RC,10009,CPT,2,EAPG,,,,outpatient,facility,,,1817.00,545.10,933.72,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MRI Exam,10315194,CDM,0761,RC,10011,CPT,,,,,,outpatient,facility,,,1817.00,545.10,118.0,1544.45,,1122.91,,,percent of total billed charges,,,,,,,,,886.70,,,percent of total billed charges,,,916.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.23,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,908.5,,,percent of total billed charges,,,,,,,,,1362.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1544.45,,,percent of total billed charges,,,835.82,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MRI Exam,10315194,CDM,0761,RC,10011,CPT,05071,APC,,,,outpatient,facility,,,1817.00,545.10,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
MRI Exam,10315194,CDM,0761,RC,10011,CPT,2,EAPG,,,,outpatient,facility,,,1817.00,545.10,933.72,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,993.51,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10315202,CDM,0761,RC,36572,CPT,,,,,,outpatient,facility,,,1945.00,583.50,118.0,1653.25,,1202.01,,,percent of total billed charges,,,,,,,,,949.16,,,percent of total billed charges,,,981.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.63,,,percent of total billed charges,,,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,972.5,,,percent of total billed charges,,,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10315202,CDM,0761,RC,36572,CPT,05181,APC,,,,outpatient,facility,,,1945.00,583.50,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
SP Exam,10315202,CDM,0761,RC,36572,CPT,75,EAPG,,,,outpatient,facility,,,1945.00,583.50,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10315207,CDM,0761,RC,36584,CPT,,,,,,outpatient,facility,,,3430.00,1029.00,118.0,2915.5,,2119.74,,,percent of total billed charges,,,,,,,,,1673.84,,,percent of total billed charges,,,1730.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1457.75,,,percent of total billed charges,,,,,,,,,2572.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1715.0,,,percent of total billed charges,,,,,,,,,2572.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2915.5,,,percent of total billed charges,,,1577.8,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10315207,CDM,0761,RC,36584,CPT,05182,APC,,,,outpatient,facility,,,3430.00,1029.00,1428.90,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,1428.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,1428.90,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1428.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
SP Exam,10315207,CDM,0761,RC,36584,CPT,75,EAPG,,,,outpatient,facility,,,3430.00,1029.00,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MSP Exam,10315210,CDM,0761,RC,50436,CPT,,,,,,outpatient,facility,,,6832.00,2049.60,118.0,5807.20,,4222.18,,,percent of total billed charges,,,,,,,,,3334.02,,,percent of total billed charges,,,3446.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2903.60,,,percent of total billed charges,,,,,,,,,5124.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3416.0,,,percent of total billed charges,,,,,,,,,5124.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5807.20,,,percent of total billed charges,,,3142.72,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MSP Exam,10315210,CDM,0761,RC,50436,CPT,05374,APC,,,,outpatient,facility,,,6832.00,2049.60,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
MSP Exam,10315210,CDM,0761,RC,50436,CPT,170,EAPG,,,,outpatient,facility,,,6832.00,2049.60,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MSP Exam,10315212,CDM,0761,RC,50437,CPT,,,,,,outpatient,facility,,,9180.00,2754.00,118.0,7803.0,,5673.24,,,percent of total billed charges,,,,,,,,,4479.84,,,percent of total billed charges,,,4630.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4590.0,,,percent of total billed charges,,,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7803.0,,,percent of total billed charges,,,4222.80,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MSP Exam,10315212,CDM,0761,RC,50437,CPT,05374,APC,,,,outpatient,facility,,,9180.00,2754.00,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
MSP Exam,10315212,CDM,0761,RC,50437,CPT,170,EAPG,,,,outpatient,facility,,,9180.00,2754.00,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10315215,CDM,0360,RC,0505T,CPT,,,,,,outpatient,facility,,,30331.00,9099.30,5463.36,25781.35,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,15298.96,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,22748.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18583.0,,,case rate,,,,,,,,,22748.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25781.35,,,percent of total billed charges,,,13952.26,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10315215,CDM,0360,RC,0505T,CPT,05193,APC,,,,outpatient,facility,,,30331.00,9099.30,10864.55,24977.68,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22877.78,,,fee schedule,,,,,,,,,11081.84,,,fee schedule,,,24977.68,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22546.22,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,11081.84,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,11081.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10972.86,,,fee schedule,,,,,,,,
SP Exam,10315215,CDM,0360,RC,0505T,CPT,79,EAPG,,,,outpatient,facility,,,30331.00,9099.30,6925.40,15648.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15648.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13301.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6925.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,7617.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10315235,CDM,0351,RC,70496,CPT,,,,,,outpatient,facility,,,1478.00,443.40,375.0,1256.3,,443.74,,,fee schedule,,Paid in addition to outpatient services ,,,,,,,375.0,,,fee schedule,,Paid in addition to outpatient services ,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.0,,,per diem,,,,,,,,,1108.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,,1108.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1256.3,,,percent of total billed charges,,,679.88,,,percent of total billed charges,,,,,,,,,385.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10315235,CDM,0351,RC,70496,CPT,05571,APC,,,,outpatient,facility,,,1478.00,443.40,163.74,392.09,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,359.12,,,fee schedule,,,163.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",174.12,,,fee schedule,,,392.09,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,353.92,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,163.74,,,fee schedule,,,174.12,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,,,,,,,163.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",174.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,170.71,,,fee schedule,,,,,,,,,172.41,,,fee schedule,,,,,,,,
CT Exam,10315235,CDM,0351,RC,70496,CPT,302,EAPG,,,,outpatient,facility,,,1478.00,443.40,540.35,814.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,814.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,691.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,540.35,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,540.35,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,540.35,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,552.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,607.66,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BASEPLATE TIBIAL SZ8 X_5536-B-800 X_STRYKER,10315354,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE TIBIAL SZ8 X_5536-B-800 X_STRYKER,10315354,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP PATELLA SZ A35 35X39X10MM,10315355,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP PATELLA SZ A35 35X39X10MM,10315355,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE TITANIUM FT LP,10315356,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE TITANIUM FT LP,10315356,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CAN LOK LP 38X3.5MM,10315357,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CAN LOK LP 38X3.5MM,10315357,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VENTRIO ST HERNIA PATCH OVAL 3.1X4.7IN X_5950,10315466,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2339.00,701.70,907.53,1988.15,,,,,,,,,,,,,,,,,,,,907.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1754.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1169.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1988.15,,,percent of total billed charges,,,1052.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VENTRIO ST HERNIA PATCH OVAL 3.1X4.7IN X_5950,10315466,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2339.00,701.70,994.07,1988.15,,,,,,,,,,,,,service not payable,,,,,,,1179.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1754.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1169.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1754.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1988.15,,,percent of total billed charges,,,1075.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG COMP NR 14H 5.0MM X_627544 X_STRYKER,10315467,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10153.00,3045.90,3939.36,8630.05,,4974.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4264.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3939.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7614.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8630.05,,,percent of total billed charges,,,4568.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG COMP NR 14H 5.0MM X_627544 X_STRYKER,10315467,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10153.00,3045.90,4264.26,8630.05,,4974.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4264.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5121.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4315.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7614.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5076.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7614.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8630.05,,,percent of total billed charges,,,4670.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PERIPRSTH LCKG 5X8MM X_661308 X_STRYKER,10315468,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1496.00,448.80,580.45,1271.60,,,,,,,,,,,,,,,,,,,,580.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,748.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1271.60,,,percent of total billed charges,,,673.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERIPRSTH LCKG 5X8MM X_661308 X_STRYKER,10315468,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1496.00,448.80,635.80,1271.60,,,,,,,,,,,,,service not payable,,,,,,,754.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,635.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,748.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1122.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1271.60,,,percent of total billed charges,,,688.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL JOURNEY UNI SZ3 X_71422433 X_SMITH NEP,10315469,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4284.00,1285.20,1662.19,3641.40,,,,,,,,,,,,,,,,,,,,1662.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3641.40,,,percent of total billed charges,,,1927.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL JOURNEY UNI SZ3 X_71422433 X_SMITH NEP,10315469,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4284.00,1285.20,1820.7,3641.40,,,,,,,,,,,,,service not payable,,,,,,,2160.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3641.40,,,percent of total billed charges,,,1970.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL JOURNEY SZ3 X_71422353 X_SMITH N,10315470,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6105.00,1831.50,2368.74,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5189.25,,,percent of total billed charges,,,2747.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL JOURNEY SZ3 X_71422353 X_SMITH N,10315470,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6105.00,1831.50,2564.10,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3079.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5189.25,,,percent of total billed charges,,,2808.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL JOURNEY SZ3-4RM/LL8M X_71422255 X_SM,10315471,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL JOURNEY SZ3-4RM/LL8M X_71422255 X_SM,10315471,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE TIBIAL KNEE TRI SZ 7,10315472,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE TIBIAL KNEE TRI SZ 7,10315472,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA ASYM TI 40X11MM X_5552-L-401 X_STRYKER,10315474,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA ASYM TI 40X11MM X_5552-L-401 X_STRYKER,10315474,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE BRIDGE WRIST8H,10315476,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4574.00,1372.20,1774.71,3887.90,,,,,,,,,,,,,,,,,,,,1774.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.90,,,percent of total billed charges,,,2058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE BRIDGE WRIST8H,10315476,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,,,,,,,,,,,,service not payable,,,,,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL HEX 10X2.7MM,10315478,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,454.00,136.20,176.15,385.90,,,,,,,,,,,,,,,,,,,,176.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,,204.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL HEX 10X2.7MM,10315478,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,454.00,136.20,192.95,385.90,,,,,,,,,,,,,service not payable,,,,,,,229.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,340.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,,208.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL LOCK 10X2.7MM,10315479,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL LOCK 10X2.7MM,10315479,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE CARDIOMEMS .018IN X_CM2010 X_ST JUDE,10315480,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,service not payable,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLGRFT 18MM,10315481,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,2995.00,898.50,1162.06,2545.75,,,,,,,,,,,,,,,,,,,,1162.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1272.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2246.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1497.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2545.75,,,percent of total billed charges,,,1347.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLGRFT 18MM,10315481,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,2995.00,898.50,1272.88,2545.75,,,,,,,,,,,,,service not payable,,,,,,,1510.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1272.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2246.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1497.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2246.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2545.75,,,percent of total billed charges,,,1377.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE VASC 0.018IN 260CM,10315482,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,404.00,121.20,171.70,343.40,,249.67,,,percent of total billed charges,,,,,,,,service not payable,197.15,,,percent of total billed charges,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.70,,,percent of total billed charges,,,,,,,,,303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,202.0,,,percent of total billed charges,,,,,,,,service not payable,303.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,262.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,262.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST 133SX W/TB 250ML X_133SX-11-T X_ALLE,10315485,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST 133SX W/TB 250ML X_133SX-11-T X_ALLE,10315485,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST 133SX W/TB 350ML X_133SX-12-T X_ALLE,10315486,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST 133SX W/TB 350ML X_133SX-12-T X_ALLE,10315486,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST 133SX W/TB 400ML X_133SX-13-T X_ALLE,10315487,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST 133SX W/TB 400ML X_133SX-13-T X_ALLE,10315487,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST 133SX W/TB 500ML X_133SX-14-T X_ALLE,10315488,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST 133SX W/TB 500ML X_133SX-14-T X_ALLE,10315488,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST 133SX W/TB 650ML X_133SX-15-T X_ALLE,10315489,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST 133SX W/TB 650ML X_133SX-15-T X_ALLE,10315489,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST 133SX W/TB 800ML X_133SX-16-T X_ALLE,10315490,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST 133SX W/TB 800ML X_133SX-16-T X_ALLE,10315490,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPRESSION SHORT TK2 X_811305003 X_DEPUY,1031564,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,180.00,54.00,69.84,153.0,,,,,,,,,,,,,,,,,,,,69.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.0,,,percent of total billed charges,,,81.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPRESSION SHORT TK2 X_811305003 X_DEPUY,1031564,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,180.00,54.00,76.5,153.0,,,,,,,,,,,,,service not payable,,,,,,,90.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.0,,,percent of total billed charges,,,82.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPRESSION LONG TK2 X_811305004 X_DEPUY,1031565,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,153.00,45.90,59.36,130.05,,,,,,,,,,,,,,,,,,,,59.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,114.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.05,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPRESSION LONG TK2 X_811305004 X_DEPUY,1031565,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,153.00,45.90,65.02,130.05,,,,,,,,,,,,,service not payable,,,,,,,77.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,114.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,76.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,114.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.05,,,percent of total billed charges,,,70.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 130 DEG 2 HOLE X_8315-30-002 X_DEPUY,1031566,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1876.00,562.80,727.89,1594.60,,,,,,,,,,,,,,,,,,,,727.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,797.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1407.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,938.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.60,,,percent of total billed charges,,,844.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 130 DEG 2 HOLE X_8315-30-002 X_DEPUY,1031566,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1876.00,562.80,797.30,1594.60,,,,,,,,,,,,,service not payable,,,,,,,946.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,797.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1407.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,938.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1407.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1594.60,,,percent of total billed charges,,,862.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 3.5X60MM,10315677,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 3.5X60MM,10315677,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5X60MM X_AR-8935L-60 X_ARTHREX INC,10315679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X60MM X_AR-8935L-60 X_ARTHREX INC,10315679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK LP TI 4X60MM,10315681,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK LP TI 4X60MM,10315681,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SET SENSOR HEART CARDIOMEMS,10315683,CDM,0278,RC,C2624,HCPCS,,,,,,inpatient,facility,,,47862.00,14358.60,18570.46,40682.70,,23452.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20102.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,18570.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20341.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,35896.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23931.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40682.70,,,percent of total billed charges,,,21537.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SET SENSOR HEART CARDIOMEMS,10315683,CDM,0278,RC,C2624,HCPCS,,,,,,outpatient,facility,,,47862.00,14358.60,20102.04,40682.70,,23452.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20102.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,24141.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,20341.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,35896.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23931.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,35896.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,40682.70,,,percent of total billed charges,,,22016.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LOW PROFILE 4MM X_AR-8948-04 X_ARTHREX INC,10315686,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3129.00,938.70,1214.05,2659.65,,,,,,,,,,,,,,,,,,,,1214.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1329.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2346.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1564.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2659.65,,,percent of total billed charges,,,1408.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LOW PROFILE 4MM X_AR-8948-04 X_ARTHREX INC,10315686,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3129.00,938.70,1329.82,2659.65,,,,,,,,,,,,,service not payable,,,,,,,1578.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1329.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2346.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1564.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2346.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2659.65,,,percent of total billed charges,,,1439.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LAG 6.7X60MM X_AR-8967-2860 X_ARTHREX INC,10315687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1282.00,384.60,497.42,1089.7,,,,,,,,,,,,,,,,,,,,497.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,961.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,641.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1089.7,,,percent of total billed charges,,,576.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LAG 6.7X60MM X_AR-8967-2860 X_ARTHREX INC,10315687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1282.00,384.60,544.85,1089.7,,,,,,,,,,,,,service not payable,,,,,,,646.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,544.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,961.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,641.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,961.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1089.7,,,percent of total billed charges,,,589.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL 16MM X_6742-1-116 X_STRYKER,1031570,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4230.00,1269.00,1641.24,3595.5,,,,,,,,,,,,,,,,,,,,1641.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2115.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3595.5,,,percent of total billed charges,,,1903.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL 16MM X_6742-1-116 X_STRYKER,1031570,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,,,,,,,,,,,,service not payable,,,,,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2115.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER SENSIA SR X_SESR01 X_MEDTRONIC,1031574,CDM,0275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,14523.00,4356.90,5634.92,12344.55,,7116.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6099.66,,,percent of total billed charges,,Paid in addition to inpatient services ,5634.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6172.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10892.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12344.55,,,percent of total billed charges,,,6535.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER SENSIA SR X_SESR01 X_MEDTRONIC,1031574,CDM,0275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,14523.00,4356.90,6099.66,12344.55,,7116.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6099.66,,,percent of total billed charges,,Paid in addition to outpatient services ,7325.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6172.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10892.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12344.55,,,percent of total billed charges,,,6680.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BREAST 492ML X_15-492 X_ALLERGAN INC,1031575,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BREAST 492ML X_15-492 X_ALLERGAN INC,1031575,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PICC w/o Sub port or pump including image guidanc,10316006,CDM,0450,RC,36572,CPT,,,,,,outpatient,facility,,,1945.00,583.50,774.0,1653.25,,1202.01,,,percent of total billed charges,,,,,,,,,949.16,,,percent of total billed charges,,,981.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
PICC w/o Sub port or pump including image guidanc,10316006,CDM,0450,RC,36572,CPT,05181,APC,,,,outpatient,facility,,,1945.00,583.50,284.35,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,284.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,284.35,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,284.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
PICC w/o Sub port or pump including image guidanc,10316006,CDM,0450,RC,36572,CPT,75,EAPG,,,,outpatient,facility,,,1945.00,583.50,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PICC w/o Sub port or pump including image guidanc,10316009,CDM,0450,RC,36573,CPT,,,,,,outpatient,facility,,,4010.00,1203.00,774.0,3408.5,,2478.18,,,percent of total billed charges,,,,,,,,,1956.88,,,percent of total billed charges,,,2022.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3007.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3007.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3408.5,,,percent of total billed charges,,,1844.60,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
PICC w/o Sub port or pump including image guidanc,10316009,CDM,0450,RC,36573,CPT,05182,APC,,,,outpatient,facility,,,4010.00,1203.00,714.45,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,714.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,714.45,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,714.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
PICC w/o Sub port or pump including image guidanc,10316009,CDM,0450,RC,36573,CPT,75,EAPG,,,,outpatient,facility,,,4010.00,1203.00,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA biopsy w/o image guidance each addtl lesion,10316012,CDM,0450,RC,10004,CPT,,,,,,outpatient,facility,,,308.00,92.40,141.68,880.0,,190.34,,,percent of total billed charges,,,,,,,,service not payable,150.30,,,percent of total billed charges,,,155.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,261.80,,,percent of total billed charges,,,141.68,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA biopsy w/o image guidance each addtl lesion,10316012,CDM,0450,RC,10004,CPT,2,EAPG,,,,outpatient,facility,,,308.00,92.40,308.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tangential biopsy of skin single lesion,10316015,CDM,0450,RC,11102,CPT,,,,,,outpatient,facility,,,555.00,166.50,255.30,880.0,,342.99,,,percent of total billed charges,,,,,,,,,270.84,,,percent of total billed charges,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tangential biopsy of skin single lesion,10316015,CDM,0450,RC,11102,CPT,05051,APC,,,,outpatient,facility,,,555.00,166.50,91.39,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,91.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,91.39,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,91.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
Tangential biopsy of skin single lesion,10316015,CDM,0450,RC,11102,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tangential biopsy of skin ea addtl lesion,10316018,CDM,0450,RC,11103,CPT,,,,,,outpatient,facility,,,279.00,83.70,64.17,880.0,,172.42,,,percent of total billed charges,,,,,,,,service not payable,136.15,,,percent of total billed charges,,,140.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,209.25,,,percent of total billed charges,,,64.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Tangential biopsy of skin ea addtl lesion,10316018,CDM,0450,RC,11103,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Punch Biopsy of skin single lesion,10316021,CDM,0450,RC,11104,CPT,,,,,,outpatient,facility,,,555.00,166.50,255.30,880.0,,342.99,,,percent of total billed charges,,,,,,,,,270.84,,,percent of total billed charges,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Punch Biopsy of skin single lesion,10316021,CDM,0450,RC,11104,CPT,05052,APC,,,,outpatient,facility,,,555.00,166.50,183.75,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,183.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,183.75,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,183.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
Punch Biopsy of skin single lesion,10316021,CDM,0450,RC,11104,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Punch biopsy of skin ea addtl lesion,10316024,CDM,0450,RC,11105,CPT,,,,,,outpatient,facility,,,279.00,83.70,64.17,880.0,,172.42,,,percent of total billed charges,,,,,,,,service not payable,136.15,,,percent of total billed charges,,,140.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,209.25,,,percent of total billed charges,,,64.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Punch biopsy of skin ea addtl lesion,10316024,CDM,0450,RC,11105,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Incisional biopsy of skin single lesion,10316025,CDM,0450,RC,11106,CPT,,,,,,outpatient,facility,,,986.00,295.80,453.56,880.0,,609.35,,,percent of total billed charges,,,,,,,,,481.17,,,percent of total billed charges,,,497.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,838.10,,,percent of total billed charges,,,453.56,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Incisional biopsy of skin single lesion,10316025,CDM,0450,RC,11106,CPT,05053,APC,,,,outpatient,facility,,,986.00,295.80,281.52,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,281.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,281.52,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,281.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
Incisional biopsy of skin single lesion,10316025,CDM,0450,RC,11106,CPT,9,EAPG,,,,outpatient,facility,,,986.00,295.80,602.64,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Incisional biopsy of skin ea addtl lesion,10316028,CDM,0450,RC,11107,CPT,,,,,,outpatient,facility,,,494.00,148.20,113.62,880.0,,305.29,,,percent of total billed charges,,,,,,,,service not payable,241.07,,,percent of total billed charges,,,249.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,370.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,370.5,,,percent of total billed charges,,,113.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,419.90,,,percent of total billed charges,,,227.24,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Incisional biopsy of skin ea addtl lesion,10316028,CDM,0450,RC,11107,CPT,9,EAPG,,,,outpatient,facility,,,494.00,148.20,494.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Replace G Tube perc includes removal when perfor,10316031,CDM,0450,RC,43762,CPT,,,,,,outpatient,facility,,,727.00,218.10,334.42,880.0,,449.29,,,percent of total billed charges,,,,,,,,,354.78,,,percent of total billed charges,,,366.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.95,,,percent of total billed charges,,,334.42,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Replace G Tube perc includes removal when perfor,10316031,CDM,0450,RC,43762,CPT,05371,APC,,,,outpatient,facility,,,727.00,218.10,111.86,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,111.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,111.86,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,111.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
Replace G Tube perc includes removal when perfor,10316031,CDM,0450,RC,43762,CPT,130,EAPG,,,,outpatient,facility,,,727.00,218.10,565.93,2256.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2256.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1917.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1178.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1296.48,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Replace G Tube perc includes removal when perfor,10316034,CDM,0450,RC,43763,CPT,,,,,,outpatient,facility,,,727.00,218.10,334.42,880.0,,449.29,,,percent of total billed charges,,,,,,,,,354.78,,,percent of total billed charges,,,366.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.95,,,percent of total billed charges,,,334.42,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Replace G Tube perc includes removal when perfor,10316034,CDM,0450,RC,43763,CPT,05371,APC,,,,outpatient,facility,,,727.00,218.10,111.86,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,111.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,111.86,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,111.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
Replace G Tube perc includes removal when perfor,10316034,CDM,0450,RC,43763,CPT,130,EAPG,,,,outpatient,facility,,,727.00,218.10,565.93,2256.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2256.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1917.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1178.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1296.48,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM FEM ANG DIST 22X190MM,10316361,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13345.00,4003.50,5177.86,11343.25,,6539.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5604.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5177.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5671.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10008.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6672.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11343.25,,,percent of total billed charges,,,6005.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ANG DIST 22X190MM,10316361,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13345.00,4003.50,5604.90,11343.25,,6539.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5604.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6731.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5671.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10008.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6672.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10008.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11343.25,,,percent of total billed charges,,,6138.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ6 9MM X_5534-A-609 X_STRYKER OR,10316363,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ6 9MM X_5534-A-609 X_STRYKER OR,10316363,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 100CM 5X150MM,10316365,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5164.00,1549.20,2194.70,4389.40,,3191.35,,,percent of total billed charges,,,,,,,,service not payable,2520.03,,,percent of total billed charges,,,2604.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2194.70,,,percent of total billed charges,,,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2582.0,,,percent of total billed charges,,,,,,,,service not payable,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4389.40,,,percent of total billed charges,,,2375.44,,,percent of total billed charges,,,,,,,,,3356.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3356.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 100CM 5X220MM,10316366,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2821.57,5643.15,,4102.90,,,percent of total billed charges,,,,,,,,service not payable,3239.83,,,percent of total billed charges,,,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 100CM 6X150MM,10316367,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5164.00,1549.20,2194.70,4389.40,,3191.35,,,percent of total billed charges,,,,,,,,service not payable,2520.03,,,percent of total billed charges,,,2604.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2194.70,,,percent of total billed charges,,,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2582.0,,,percent of total billed charges,,,,,,,,service not payable,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4389.40,,,percent of total billed charges,,,2375.44,,,percent of total billed charges,,,,,,,,,3356.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3356.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 100CM 6X220MM,10316368,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2821.57,5643.15,,4102.90,,,percent of total billed charges,,,,,,,,service not payable,3239.83,,,percent of total billed charges,,,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 100CM 7X150MM X_LX1810071505F X_CR BA,10316369,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5164.00,1549.20,2194.70,4389.40,,3191.35,,,percent of total billed charges,,,,,,,,service not payable,2520.03,,,percent of total billed charges,,,2604.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2194.70,,,percent of total billed charges,,,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2582.0,,,percent of total billed charges,,,,,,,,service not payable,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4389.40,,,percent of total billed charges,,,2375.44,,,percent of total billed charges,,,,,,,,,3356.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3356.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 130CM 5X220MM,10316370,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2821.57,5643.15,,4102.90,,,percent of total billed charges,,,,,,,,service not payable,3239.83,,,percent of total billed charges,,,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 130CM 6X220MM,10316371,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2821.57,5643.15,,4102.90,,,percent of total billed charges,,,,,,,,service not payable,3239.83,,,percent of total billed charges,,,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 130CM 7X220MM X_LX1813072205F X_CR BA,10316372,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2821.57,5643.15,,4102.90,,,percent of total billed charges,,,,,,,,service not payable,3239.83,,,percent of total billed charges,,,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4315.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SUP CLAV 6H BRDG LFT X_628146 X_STRYKER ORTH,10316374,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5422.00,1626.60,2103.74,4608.70,,2656.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2277.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2103.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2304.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4066.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2711.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4608.70,,,percent of total billed charges,,,2439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SUP CLAV 6H BRDG LFT X_628146 X_STRYKER ORTH,10316374,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5422.00,1626.60,2277.24,4608.70,,2656.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2277.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2734.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2304.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4066.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2711.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4066.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4608.70,,,percent of total billed charges,,,2494.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL GAMMA 3S RT 10X440MM 125D X_3425-0440S X_STRY,10316375,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6293.00,1887.90,2441.68,5349.05,,3083.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2441.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4719.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.05,,,percent of total billed charges,,,2831.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL GAMMA 3S RT 10X440MM 125D X_3425-0440S X_STRY,10316375,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6293.00,1887.90,2643.06,5349.05,,3083.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4719.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3146.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4719.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.05,,,percent of total billed charges,,,2894.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC TIP TRNSJUGLR 8-10,10316376,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15198.00,4559.40,5896.82,12918.30,,7447.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6383.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5896.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11398.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7599.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12918.30,,,percent of total billed charges,,,6839.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC TIP TRNSJUGLR 8-10,10316376,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15198.00,4559.40,6383.16,12918.30,,7447.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6383.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7665.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6459.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11398.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7599.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11398.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12918.30,,,percent of total billed charges,,,6991.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Stent Viatorr Controlled Expansion 8-10MMX7CM/2CM,10316377,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,14303.00,4290.90,5549.56,12157.55,,7008.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6007.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5549.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6078.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12157.55,,,percent of total billed charges,,,6436.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Stent Viatorr Controlled Expansion 8-10MMX7CM/2CM,10316377,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,14303.00,4290.90,6007.26,12157.55,,7008.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6007.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7214.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6078.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12157.55,,,percent of total billed charges,,,6579.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 9X11X34-8 X_5291348 X_NUVASIVE,10316873,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 9X11X34-8 X_5291348 X_NUVASIVE,10316873,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 4.5 POLYAX 6.5X50MM,10316874,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 4.5 POLYAX 6.5X50MM,10316874,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO DBM 10MM X_7775010 X_STRYKER SPINE,10316875,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,4273.00,1281.90,1657.92,3632.05,,,,,,,,,,,,,,,,,,,,1657.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1816.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3204.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3632.05,,,percent of total billed charges,,,1922.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY BIO DBM 10MM X_7775010 X_STRYKER SPINE,10316875,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,4273.00,1281.90,1816.02,3632.05,,,,,,,,,,,,,service not payable,,,,,,,2155.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1816.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3204.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3204.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3632.05,,,percent of total billed charges,,,1965.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY BIO DBM 10MM X_7775010 X_STRYKER SPINE,10316875,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,4273.00,1281.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR ROD POST LG,10316876,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3803.00,1140.90,1475.56,3232.55,,,,,,,,,,,,,,,,,,,,1475.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1616.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2852.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1901.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3232.55,,,percent of total billed charges,,,1711.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR ROD POST LG,10316876,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3803.00,1140.90,1616.27,3232.55,,,,,,,,,,,,,service not payable,,,,,,,1918.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1616.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2852.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1901.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2852.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3232.55,,,percent of total billed charges,,,1749.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 1.50X15MM,10316877,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.00X15MM,10316878,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF-FNA biopsy w/o image guidance each addtl les,10317216,CDM,0761,RC,10004,CPT,,,,,,outpatient,facility,,,308.00,92.40,118.0,261.80,,190.34,,,percent of total billed charges,,,,,,,,service not payable,150.30,,,percent of total billed charges,,,155.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,,,,,,,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,154.0,,,percent of total billed charges,,,,,,,,service not payable,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,261.80,,,percent of total billed charges,,,141.68,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF-FNA biopsy w/o image guidance each addtl les,10317216,CDM,0761,RC,10004,CPT,2,EAPG,,,,outpatient,facility,,,308.00,92.40,308.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF-Punch biopsy of skin single lesion,10317219,CDM,0761,RC,11104,CPT,,,,,,outpatient,facility,,,555.00,166.50,118.0,471.75,,342.99,,,percent of total billed charges,,,,,,,,,270.84,,,percent of total billed charges,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.88,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,277.5,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
BCF-Punch biopsy of skin single lesion,10317219,CDM,0761,RC,11104,CPT,05052,APC,,,,outpatient,facility,,,555.00,166.50,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
BCF-Punch biopsy of skin single lesion,10317219,CDM,0761,RC,11104,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF-Punch biopsy of skin ea addtl lesion,10317222,CDM,0761,RC,11105,CPT,,,,,,outpatient,facility,,,279.00,83.70,118.0,237.15,,172.42,,,percent of total billed charges,,,,,,,,service not payable,136.15,,,percent of total billed charges,,,140.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,118.58,,,percent of total billed charges,,,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,209.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF-Punch biopsy of skin ea addtl lesion,10317222,CDM,0761,RC,11105,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF-Tangential biopsy of skin single lesion,10317225,CDM,0761,RC,11102,CPT,,,,,,outpatient,facility,,,555.00,166.50,118.0,471.75,,342.99,,,percent of total billed charges,,,,,,,,,270.84,,,percent of total billed charges,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.88,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,277.5,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
BCF-Tangential biopsy of skin single lesion,10317225,CDM,0761,RC,11102,CPT,05051,APC,,,,outpatient,facility,,,555.00,166.50,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
BCF-Tangential biopsy of skin single lesion,10317225,CDM,0761,RC,11102,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF-Tangential biopsy of skin ea addtl lesion,10317228,CDM,0761,RC,11103,CPT,,,,,,outpatient,facility,,,279.00,83.70,118.0,237.15,,172.42,,,percent of total billed charges,,,,,,,,service not payable,136.15,,,percent of total billed charges,,,140.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,118.58,,,percent of total billed charges,,,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,209.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF-Tangential biopsy of skin ea addtl lesion,10317228,CDM,0761,RC,11103,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF-Incisional biopsy of skin single lesion,10317231,CDM,0761,RC,11106,CPT,,,,,,outpatient,facility,,,986.00,295.80,118.0,838.10,,609.35,,,percent of total billed charges,,,,,,,,,481.17,,,percent of total billed charges,,,497.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,493.0,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,838.10,,,percent of total billed charges,,,453.56,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
BCF-Incisional biopsy of skin single lesion,10317231,CDM,0761,RC,11106,CPT,05053,APC,,,,outpatient,facility,,,986.00,295.80,563.05,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,563.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,563.05,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,563.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
BCF-Incisional biopsy of skin single lesion,10317231,CDM,0761,RC,11106,CPT,9,EAPG,,,,outpatient,facility,,,986.00,295.80,602.64,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BCF-Incisional biopsy of skin ea addtl lesion,10317234,CDM,0761,RC,11107,CPT,,,,,,outpatient,facility,,,494.00,148.20,118.0,419.90,,305.29,,,percent of total billed charges,,,,,,,,service not payable,241.07,,,percent of total billed charges,,,249.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,370.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,247.0,,,percent of total billed charges,,,,,,,,service not payable,370.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.90,,,percent of total billed charges,,,227.24,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BCF-Incisional biopsy of skin ea addtl lesion,10317234,CDM,0761,RC,11107,CPT,9,EAPG,,,,outpatient,facility,,,494.00,148.20,494.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INF-PICC w/o Sub port or pump including image gui,10317251,CDM,0940,RC,36572,CPT,,,,,,outpatient,facility,,,1945.00,583.50,826.63,1653.25,,1202.01,,,percent of total billed charges,,,,,,,,,949.16,,,percent of total billed charges,,,981.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.63,,,percent of total billed charges,,,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,972.5,,,percent of total billed charges,,,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,949.0,,,per diem,,,,,,,,,,,,,,,835.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
INF-PICC w/o Sub port or pump including image gui,10317251,CDM,0940,RC,36572,CPT,05181,APC,,,,outpatient,facility,,,1945.00,583.50,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
INF-PICC w/o Sub port or pump including image gui,10317251,CDM,0940,RC,36572,CPT,75,EAPG,,,,outpatient,facility,,,1945.00,583.50,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INF-PICC w/o Sub port or pump including image gui,10317254,CDM,0940,RC,36573,CPT,,,,,,outpatient,facility,,,4010.00,1203.00,835.0,3408.5,,2478.18,,,percent of total billed charges,,,,,,,,,1956.88,,,percent of total billed charges,,,2022.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1704.25,,,percent of total billed charges,,,,,,,,,3007.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2005.0,,,percent of total billed charges,,,,,,,,,3007.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3408.5,,,percent of total billed charges,,,1844.60,,,percent of total billed charges,,,,,,,,,949.0,,,per diem,,,,,,,,,,,,,,,835.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
INF-PICC w/o Sub port or pump including image gui,10317254,CDM,0940,RC,36573,CPT,05182,APC,,,,outpatient,facility,,,4010.00,1203.00,1428.90,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,1428.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,1428.90,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1428.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
INF-PICC w/o Sub port or pump including image gui,10317254,CDM,0940,RC,36573,CPT,75,EAPG,,,,outpatient,facility,,,4010.00,1203.00,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317258,CDM,0920,RC,92273,CPT,,,,,,outpatient,facility,,,792.00,237.60,336.60,1813.0,,489.46,,,percent of total billed charges,,,,,,,,,386.5,,,percent of total billed charges,,,399.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.60,,,percent of total billed charges,,,,,,,,,594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.0,,,percent of total billed charges,,,,,,,,,594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,673.20,,,percent of total billed charges,,,364.32,,,percent of total billed charges,,,,,,,,,1813.0,,,per diem,,,,,,,,,,,,,,,1595.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317258,CDM,0920,RC,92273,CPT,05722,APC,,,,outpatient,facility,,,792.00,237.60,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317258,CDM,0920,RC,92273,CPT,419,EAPG,,,,outpatient,facility,,,792.00,237.60,109.60,139.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,111.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,126.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,139.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317259,CDM,0920,RC,92274,CPT,,,,,,outpatient,facility,,,427.00,128.10,181.47,1813.0,,263.89,,,percent of total billed charges,,,,,,,,,208.38,,,percent of total billed charges,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.47,,,percent of total billed charges,,,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.5,,,percent of total billed charges,,,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,1813.0,,,per diem,,,,,,,,,,,,,,,1595.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317259,CDM,0920,RC,92274,CPT,05721,APC,,,,outpatient,facility,,,427.00,128.10,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317259,CDM,0920,RC,92274,CPT,419,EAPG,,,,outpatient,facility,,,427.00,128.10,109.60,139.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,111.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,126.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,139.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317260,CDM,0920,RC,0509T,CPT,,,,,,outpatient,facility,,,427.00,128.10,181.47,1813.0,,263.89,,,percent of total billed charges,,,,,,,,,208.38,,,percent of total billed charges,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.47,,,percent of total billed charges,,,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,213.5,,,percent of total billed charges,,,,,,,,,320.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,1813.0,,,per diem,,,,,,,,,,,,,,,1595.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317260,CDM,0920,RC,0509T,CPT,05722,APC,,,,outpatient,facility,,,427.00,128.10,298.62,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,,,,,,,304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION,10317260,CDM,0920,RC,0509T,CPT,419,EAPG,,,,outpatient,facility,,,427.00,128.10,109.60,139.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,111.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,126.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,139.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Change Gastrostomy tube percut w/o imaging,10317291,CDM,0490,RC,43762,CPT,,,,,,outpatient,facility,,,727.00,218.10,334.42,2912.34,,727.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,366.70,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.95,,,percent of total billed charges,,,334.42,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Change Gastrostomy tube percut w/o imaging,10317291,CDM,0490,RC,43762,CPT,05371,APC,,,,outpatient,facility,,,727.00,218.10,223.71,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,223.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,223.71,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,223.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
END-Change Gastrostomy tube percut w/o imaging,10317291,CDM,0490,RC,43762,CPT,130,EAPG,,,,outpatient,facility,,,727.00,218.10,565.93,2256.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2256.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1917.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1178.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1296.48,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Change Gastrostomy tube percut w/o imaging,10317297,CDM,0490,RC,43763,CPT,,,,,,outpatient,facility,,,727.00,218.10,334.42,2912.34,,727.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,366.70,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,545.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.95,,,percent of total billed charges,,,334.42,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Change Gastrostomy tube percut w/o imaging,10317297,CDM,0490,RC,43763,CPT,05371,APC,,,,outpatient,facility,,,727.00,218.10,223.71,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,223.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,223.71,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,223.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
END-Change Gastrostomy tube percut w/o imaging,10317297,CDM,0490,RC,43763,CPT,130,EAPG,,,,outpatient,facility,,,727.00,218.10,565.93,2256.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2256.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1917.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1178.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1296.48,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-FNA biopsy w/o image guidance each add lesio,10317305,CDM,0490,RC,10004,CPT,,,,,,outpatient,facility,,,308.00,92.40,141.68,2912.34,,308.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,155.36,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,261.80,,,percent of total billed charges,,,141.68,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-FNA biopsy w/o image guidance each add lesio,10317305,CDM,0490,RC,10004,CPT,2,EAPG,,,,outpatient,facility,,,308.00,92.40,308.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Tangential bx of skin single lesion,10317316,CDM,0490,RC,11102,CPT,,,,,,outpatient,facility,,,555.00,166.50,255.30,2912.34,,555.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,279.94,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Tangential bx of skin single lesion,10317316,CDM,0490,RC,11102,CPT,05051,APC,,,,outpatient,facility,,,555.00,166.50,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
END-Tangential bx of skin single lesion,10317316,CDM,0490,RC,11102,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Tangential bx of skin ea addtl lesion,10317323,CDM,0490,RC,11103,CPT,,,,,,outpatient,facility,,,279.00,83.70,128.34,2912.34,,279.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,140.73,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,209.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Tangential bx of skin ea addtl lesion,10317323,CDM,0490,RC,11103,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Punch Bx of skin single lesion,10317334,CDM,0490,RC,11104,CPT,,,,,,outpatient,facility,,,555.00,166.50,255.30,2912.34,,555.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,279.94,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Punch Bx of skin single lesion,10317334,CDM,0490,RC,11104,CPT,05052,APC,,,,outpatient,facility,,,555.00,166.50,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
END-Punch Bx of skin single lesion,10317334,CDM,0490,RC,11104,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Punch bx of skin ea addtl lesion,10317345,CDM,0490,RC,11105,CPT,,,,,,outpatient,facility,,,279.00,83.70,128.34,2912.34,,279.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,140.73,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,209.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Punch bx of skin ea addtl lesion,10317345,CDM,0490,RC,11105,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Incisional bx of skin single lesion,10317349,CDM,0490,RC,11106,CPT,,,,,,outpatient,facility,,,986.00,295.80,453.56,2912.34,,986.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,497.34,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,838.10,,,percent of total billed charges,,,453.56,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Incisional bx of skin single lesion,10317349,CDM,0490,RC,11106,CPT,05053,APC,,,,outpatient,facility,,,986.00,295.80,563.05,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,563.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,563.05,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,563.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
END-Incisional bx of skin single lesion,10317349,CDM,0490,RC,11106,CPT,9,EAPG,,,,outpatient,facility,,,986.00,295.80,602.64,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Incisional bx of skin ea addtl lesion,10317357,CDM,0490,RC,11107,CPT,,,,,,outpatient,facility,,,494.00,148.20,227.24,2912.34,,494.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,249.17,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,370.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,370.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.90,,,percent of total billed charges,,,227.24,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Incisional bx of skin ea addtl lesion,10317357,CDM,0490,RC,11107,CPT,9,EAPG,,,,outpatient,facility,,,494.00,148.20,494.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-FNA biopsy w/o image guidance each additional,10317371,CDM,0761,RC,10004,CPT,,,,,,outpatient,facility,,,308.00,92.40,118.0,261.80,,190.34,,,percent of total billed charges,,,,,,,,service not payable,150.30,,,percent of total billed charges,,,155.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,,,,,,,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,154.0,,,percent of total billed charges,,,,,,,,service not payable,231.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,261.80,,,percent of total billed charges,,,141.68,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-FNA biopsy w/o image guidance each additional,10317371,CDM,0761,RC,10004,CPT,2,EAPG,,,,outpatient,facility,,,308.00,92.40,308.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,308.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Tangential bx skin single lesion,10317376,CDM,0761,RC,11102,CPT,,,,,,outpatient,facility,,,555.00,166.50,118.0,471.75,,342.99,,,percent of total billed charges,,,,,,,,,270.84,,,percent of total billed charges,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.88,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,277.5,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Tangential bx skin single lesion,10317376,CDM,0761,RC,11102,CPT,05051,APC,,,,outpatient,facility,,,555.00,166.50,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Tangential bx skin single lesion,10317376,CDM,0761,RC,11102,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Tangential bx skin ea addtl lesion,10317381,CDM,0761,RC,11103,CPT,,,,,,outpatient,facility,,,279.00,83.70,118.0,237.15,,172.42,,,percent of total billed charges,,,,,,,,service not payable,136.15,,,percent of total billed charges,,,140.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,118.58,,,percent of total billed charges,,,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,209.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Tangential bx skin ea addtl lesion,10317381,CDM,0761,RC,11103,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Punch Bx skin single lesion,10317390,CDM,0761,RC,11104,CPT,,,,,,outpatient,facility,,,555.00,166.50,118.0,471.75,,342.99,,,percent of total billed charges,,,,,,,,,270.84,,,percent of total billed charges,,,279.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.88,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,277.5,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.75,,,percent of total billed charges,,,255.30,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Punch Bx skin single lesion,10317390,CDM,0761,RC,11104,CPT,05052,APC,,,,outpatient,facility,,,555.00,166.50,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
WC-Punch Bx skin single lesion,10317390,CDM,0761,RC,11104,CPT,9,EAPG,,,,outpatient,facility,,,555.00,166.50,555.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Punch bx skin ea additional lesion,10317399,CDM,0761,RC,11105,CPT,,,,,,outpatient,facility,,,279.00,83.70,118.0,237.15,,172.42,,,percent of total billed charges,,,,,,,,service not payable,136.15,,,percent of total billed charges,,,140.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,118.58,,,percent of total billed charges,,,,,,,,,209.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,209.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,128.34,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Punch bx skin ea additional lesion,10317399,CDM,0761,RC,11105,CPT,9,EAPG,,,,outpatient,facility,,,279.00,83.70,279.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,279.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Incisional bx skin single lesion,10317404,CDM,0761,RC,11106,CPT,,,,,,outpatient,facility,,,986.00,295.80,118.0,838.10,,609.35,,,percent of total billed charges,,,,,,,,,481.17,,,percent of total billed charges,,,497.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,493.0,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,838.10,,,percent of total billed charges,,,453.56,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Incisional bx skin single lesion,10317404,CDM,0761,RC,11106,CPT,05053,APC,,,,outpatient,facility,,,986.00,295.80,563.05,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,563.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,563.05,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,563.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
WC-Incisional bx skin single lesion,10317404,CDM,0761,RC,11106,CPT,9,EAPG,,,,outpatient,facility,,,986.00,295.80,602.64,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Incisional bx skin ea addtl lesion,10317413,CDM,0761,RC,11107,CPT,,,,,,outpatient,facility,,,494.00,148.20,118.0,419.90,,305.29,,,percent of total billed charges,,,,,,,,service not payable,241.07,,,percent of total billed charges,,,249.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,370.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,247.0,,,percent of total billed charges,,,,,,,,service not payable,370.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.90,,,percent of total billed charges,,,227.24,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Incisional bx skin ea addtl lesion,10317413,CDM,0761,RC,11107,CPT,9,EAPG,,,,outpatient,facility,,,494.00,148.20,494.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,494.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PICC w/o Sub port or pump incl image guidance < 5,10317418,CDM,0490,RC,36572,CPT,,,,,,outpatient,facility,,,1888.00,566.40,868.48,2912.34,,1888.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,952.31,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1416.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1416.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1604.8,,,percent of total billed charges,,,868.48,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
PICC w/o Sub port or pump incl image guidance < 5,10317418,CDM,0490,RC,36572,CPT,05181,APC,,,,outpatient,facility,,,1888.00,566.40,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
PICC w/o Sub port or pump incl image guidance < 5,10317418,CDM,0490,RC,36572,CPT,75,EAPG,,,,outpatient,facility,,,1888.00,566.40,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PICC w/o Sub port or pump incl image guidance  >,10317422,CDM,0490,RC,36573,CPT,,,,,,outpatient,facility,,,3894.00,1168.20,1791.24,3795.64,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1964.13,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,2920.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,2920.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3309.90,,,percent of total billed charges,,,1791.24,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
PICC w/o Sub port or pump incl image guidance  >,10317422,CDM,0490,RC,36573,CPT,05182,APC,,,,outpatient,facility,,,3894.00,1168.20,1428.90,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,1428.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,1428.90,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1428.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
PICC w/o Sub port or pump incl image guidance  >,10317422,CDM,0490,RC,36573,CPT,75,EAPG,,,,outpatient,facility,,,3894.00,1168.20,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA biopsy w/o image guidance ea addtl lesion,10317426,CDM,0490,RC,10004,CPT,,,,,,outpatient,facility,,,299.00,89.70,137.54,2912.34,,299.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,150.82,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,224.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,224.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,254.15,,,percent of total billed charges,,,137.54,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA biopsy w/o image guidance ea addtl lesion,10317426,CDM,0490,RC,10004,CPT,2,EAPG,,,,outpatient,facility,,,299.00,89.70,299.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,299.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,299.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tangential bx of skin sgle lesion,10317430,CDM,0490,RC,11102,CPT,,,,,,outpatient,facility,,,538.00,161.40,247.48,2912.34,,538.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,271.37,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,403.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,403.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,457.30,,,percent of total billed charges,,,247.48,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tangential bx of skin sgle lesion,10317430,CDM,0490,RC,11102,CPT,05051,APC,,,,outpatient,facility,,,538.00,161.40,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
Tangential bx of skin sgle lesion,10317430,CDM,0490,RC,11102,CPT,9,EAPG,,,,outpatient,facility,,,538.00,161.40,538.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,538.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,538.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tangential bx of skin ea add lesion,10317434,CDM,0490,RC,11103,CPT,,,,,,outpatient,facility,,,270.00,81.00,124.2,2912.34,,270.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,136.19,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,202.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,202.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,229.5,,,percent of total billed charges,,,124.2,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Tangential bx of skin ea add lesion,10317434,CDM,0490,RC,11103,CPT,9,EAPG,,,,outpatient,facility,,,270.00,81.00,270.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,270.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,270.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Punch Bx of skin sgle lesion,10317438,CDM,0490,RC,11104,CPT,,,,,,outpatient,facility,,,538.00,161.40,247.48,2912.34,,538.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,271.37,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,403.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,403.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,457.30,,,percent of total billed charges,,,247.48,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Punch Bx of skin sgle lesion,10317438,CDM,0490,RC,11104,CPT,05052,APC,,,,outpatient,facility,,,538.00,161.40,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
Punch Bx of skin sgle lesion,10317438,CDM,0490,RC,11104,CPT,9,EAPG,,,,outpatient,facility,,,538.00,161.40,538.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,538.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,538.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Punch bx of skin ea add lesion,10317442,CDM,0490,RC,11105,CPT,,,,,,outpatient,facility,,,270.00,81.00,124.2,2912.34,,270.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,136.19,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,202.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,202.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,229.5,,,percent of total billed charges,,,124.2,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Punch bx of skin ea add lesion,10317442,CDM,0490,RC,11105,CPT,9,EAPG,,,,outpatient,facility,,,270.00,81.00,270.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,270.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,270.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Incisional bx of skin sgle lesion,10317446,CDM,0490,RC,11106,CPT,,,,,,outpatient,facility,,,957.00,287.10,440.22,2912.34,,957.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,482.71,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,717.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,717.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,813.45,,,percent of total billed charges,,,440.22,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Incisional bx of skin sgle lesion,10317446,CDM,0490,RC,11106,CPT,05053,APC,,,,outpatient,facility,,,957.00,287.10,563.05,1348.23,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1234.88,,,fee schedule,,,563.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",598.76,,,fee schedule,,,1348.23,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,1216.98,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,563.05,,,fee schedule,,,598.76,,,fee schedule,,,,,,,,,587.02,,,fee schedule,,,,,,,,,563.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",598.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,,,,,,,587.02,,,fee schedule,,,,,,,,,592.87,,,fee schedule,,,,,,,,
Incisional bx of skin sgle lesion,10317446,CDM,0490,RC,11106,CPT,9,EAPG,,,,outpatient,facility,,,957.00,287.10,602.64,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,611.75,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Incisional bx of skin ea add lesion,10317450,CDM,0490,RC,11107,CPT,,,,,,outpatient,facility,,,479.00,143.70,220.34,2912.34,,479.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,241.61,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,359.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,359.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,407.15,,,percent of total billed charges,,,220.34,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Incisional bx of skin ea add lesion,10317450,CDM,0490,RC,11107,CPT,9,EAPG,,,,outpatient,facility,,,479.00,143.70,479.0,3592.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3592.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3053.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,479.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,479.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,602.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,662.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Removal of Loop Recorder,10317454,CDM,0490,RC,33286,CPT,,,,,,outpatient,facility,,,2680.00,804.00,1232.8,2912.34,,2680.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1351.79,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2010.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2010.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2278.0,,,percent of total billed charges,,,1232.8,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal of Loop Recorder,10317454,CDM,0490,RC,33286,CPT,05071,APC,,,,outpatient,facility,,,2680.00,804.00,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Removal of Loop Recorder,10317454,CDM,0490,RC,33286,CPT,74,EAPG,,,,outpatient,facility,,,2680.00,804.00,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Implant Subcut Cardiac Monitor (loop recorder) in,10317458,CDM,0481,RC,33285,CPT,,,,,,outpatient,facility,,,23226.00,6967.80,2912.34,19742.10,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,11715.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,17419.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,17419.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19742.10,,,percent of total billed charges,,,10683.96,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Implant Subcut Cardiac Monitor (loop recorder) in,10317458,CDM,0481,RC,33285,CPT,05222,APC,,,,outpatient,facility,,,23226.00,6967.80,7612.46,18227.89,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16695.46,,,fee schedule,,,7612.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8095.12,,,fee schedule,,,18227.89,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16453.5,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,7612.46,,,fee schedule,,,8095.12,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,7612.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",8095.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,8015.43,,,fee schedule,,,,,,,,
Implant Subcut Cardiac Monitor (loop recorder) in,10317458,CDM,0481,RC,33285,CPT,86,EAPG,,,,outpatient,facility,,,23226.00,6967.80,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Explant Subcut Cardiac Monitor (loop recorder),10317459,CDM,0481,RC,33286,CPT,,,,,,outpatient,facility,,,2760.00,828.00,1269.60,2912.34,,2760.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1392.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2070.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2070.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2346.0,,,percent of total billed charges,,,1269.60,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Explant Subcut Cardiac Monitor (loop recorder),10317459,CDM,0481,RC,33286,CPT,05071,APC,,,,outpatient,facility,,,2760.00,828.00,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
Explant Subcut Cardiac Monitor (loop recorder),10317459,CDM,0481,RC,33286,CPT,74,EAPG,,,,outpatient,facility,,,2760.00,828.00,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA Ea Add Lesion-US,10317551,CDM,0761,RC,10006,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA Ea Add Lesion-US,10317551,CDM,0761,RC,10006,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA Ea Add Lesion-US,10317607,CDM,0761,RC,10006,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA Ea Add Lesion-US,10317607,CDM,0761,RC,10006,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA Ea Add Lesion-Fluoro,10317608,CDM,0761,RC,10008,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA Ea Add Lesion-Fluoro,10317608,CDM,0761,RC,10008,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA Ea Add Lesion-CT,10317609,CDM,0761,RC,10010,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA Ea Add Lesion-CT,10317609,CDM,0761,RC,10010,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA ea add Lesion-MR,10317610,CDM,0761,RC,10012,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA ea add Lesion-MR,10317610,CDM,0761,RC,10012,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA Ea Add Lesion-Fluoro,10317611,CDM,0761,RC,10008,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA Ea Add Lesion-Fluoro,10317611,CDM,0761,RC,10008,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA Ea Add Lesion-CT,10317612,CDM,0761,RC,10010,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA Ea Add Lesion-CT,10317612,CDM,0761,RC,10010,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FNA ea add Lesion-MR,10317613,CDM,0761,RC,10012,CPT,,,,,,outpatient,facility,,,909.00,272.70,118.0,772.65,,561.76,,,percent of total billed charges,,,,,,,,service not payable,443.59,,,percent of total billed charges,,,458.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,386.32,,,percent of total billed charges,,,,,,,,,681.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,service not payable,681.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,772.65,,,percent of total billed charges,,,418.14,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA ea add Lesion-MR,10317613,CDM,0761,RC,10012,CPT,2,EAPG,,,,outpatient,facility,,,909.00,272.70,909.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,909.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Removal Leadless Pacemaker Rt ventricular,10317614,CDM,0761,RC,33275,CPT,,,,,,outpatient,facility,,,8286.00,2485.80,118.0,7043.10,,5120.75,,,percent of total billed charges,,,,,,,,,4043.57,,,percent of total billed charges,,,4179.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3521.55,,,percent of total billed charges,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4143.0,,,percent of total billed charges,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7043.10,,,percent of total billed charges,,,3811.56,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal Leadless Pacemaker Rt ventricular,10317614,CDM,0761,RC,33275,CPT,05183,APC,,,,outpatient,facility,,,8286.00,2485.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Removal Leadless Pacemaker Rt ventricular,10317614,CDM,0761,RC,33275,CPT,87,EAPG,,,,outpatient,facility,,,8286.00,2485.80,8286.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intro Guide Neph Perc Existing,10317615,CDM,0761,RC,50436,CPT,,,,,,outpatient,facility,,,6832.00,2049.60,118.0,5807.20,,4222.18,,,percent of total billed charges,,,,,,,,,3334.02,,,percent of total billed charges,,,3446.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2903.60,,,percent of total billed charges,,,,,,,,,5124.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3416.0,,,percent of total billed charges,,,,,,,,,5124.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5807.20,,,percent of total billed charges,,,3142.72,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Intro Guide Neph Perc Existing,10317615,CDM,0761,RC,50436,CPT,05374,APC,,,,outpatient,facility,,,6832.00,2049.60,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
Intro Guide Neph Perc Existing,10317615,CDM,0761,RC,50436,CPT,170,EAPG,,,,outpatient,facility,,,6832.00,2049.60,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intro Guide Neph Perc New,10317616,CDM,0761,RC,50437,CPT,,,,,,outpatient,facility,,,9182.00,2754.60,118.0,7804.70,,5674.48,,,percent of total billed charges,,,,,,,,,4480.82,,,percent of total billed charges,,,4631.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3902.35,,,percent of total billed charges,,,,,,,,,6886.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4591.0,,,percent of total billed charges,,,,,,,,,6886.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7804.70,,,percent of total billed charges,,,4223.72,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Intro Guide Neph Perc New,10317616,CDM,0761,RC,50437,CPT,05374,APC,,,,outpatient,facility,,,9182.00,2754.60,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
Intro Guide Neph Perc New,10317616,CDM,0761,RC,50437,CPT,170,EAPG,,,,outpatient,facility,,,9182.00,2754.60,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Dilation of Ureter or Urethra,10317617,CDM,0320,RC,74485,CPT,,,,,,outpatient,facility,,,5457.00,1637.10,139.43,4638.45,,186.86,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,139.43,,,fee schedule,,,2752.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2319.22,,,percent of total billed charges,,,,,,,,,4092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2728.5,,,percent of total billed charges,,,,,,,,,4092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4638.45,,,percent of total billed charges,,,2510.22,,,percent of total billed charges,,,,,,,,,4269.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Dilation of Ureter or Urethra,10317617,CDM,0320,RC,74485,CPT,05373,APC,,,,outpatient,facility,,,5457.00,1637.10,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
Dilation of Ureter or Urethra,10317617,CDM,0320,RC,74485,CPT,474,EAPG,,,,outpatient,facility,,,5457.00,1637.10,294.16,697.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,592.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,436.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,480.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Removal Leadless Pacemaker Rt ventricular,10317618,CDM,0761,RC,33275,CPT,,,,,,outpatient,facility,,,8286.00,2485.80,118.0,7043.10,,5120.75,,,percent of total billed charges,,,,,,,,,4043.57,,,percent of total billed charges,,,4179.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3521.55,,,percent of total billed charges,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4143.0,,,percent of total billed charges,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7043.10,,,percent of total billed charges,,,3811.56,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal Leadless Pacemaker Rt ventricular,10317618,CDM,0761,RC,33275,CPT,05183,APC,,,,outpatient,facility,,,8286.00,2485.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Removal Leadless Pacemaker Rt ventricular,10317618,CDM,0761,RC,33275,CPT,87,EAPG,,,,outpatient,facility,,,8286.00,2485.80,8286.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intro Guide Neph Perc Existing,10317619,CDM,0761,RC,50436,CPT,,,,,,outpatient,facility,,,6832.00,2049.60,118.0,5807.20,,4222.18,,,percent of total billed charges,,,,,,,,,3334.02,,,percent of total billed charges,,,3446.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2903.60,,,percent of total billed charges,,,,,,,,,5124.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3416.0,,,percent of total billed charges,,,,,,,,,5124.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5807.20,,,percent of total billed charges,,,3142.72,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Intro Guide Neph Perc Existing,10317619,CDM,0761,RC,50436,CPT,05374,APC,,,,outpatient,facility,,,6832.00,2049.60,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
Intro Guide Neph Perc Existing,10317619,CDM,0761,RC,50436,CPT,170,EAPG,,,,outpatient,facility,,,6832.00,2049.60,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intro Guide Neph Perc New,10317620,CDM,0761,RC,50437,CPT,,,,,,outpatient,facility,,,9182.00,2754.60,118.0,7804.70,,5674.48,,,percent of total billed charges,,,,,,,,,4480.82,,,percent of total billed charges,,,4631.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3902.35,,,percent of total billed charges,,,,,,,,,6886.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4591.0,,,percent of total billed charges,,,,,,,,,6886.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7804.70,,,percent of total billed charges,,,4223.72,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Intro Guide Neph Perc New,10317620,CDM,0761,RC,50437,CPT,05374,APC,,,,outpatient,facility,,,9182.00,2754.60,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
Intro Guide Neph Perc New,10317620,CDM,0761,RC,50437,CPT,170,EAPG,,,,outpatient,facility,,,9182.00,2754.60,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Dilation of Ureter or Urethra,10317621,CDM,0320,RC,74485,CPT,,,,,,outpatient,facility,,,5457.00,1637.10,139.43,4638.45,,186.86,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,139.43,,,fee schedule,,,2752.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2319.22,,,percent of total billed charges,,,,,,,,,4092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2728.5,,,percent of total billed charges,,,,,,,,,4092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4638.45,,,percent of total billed charges,,,2510.22,,,percent of total billed charges,,,,,,,,,4269.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Dilation of Ureter or Urethra,10317621,CDM,0320,RC,74485,CPT,05373,APC,,,,outpatient,facility,,,5457.00,1637.10,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
Dilation of Ureter or Urethra,10317621,CDM,0320,RC,74485,CPT,474,EAPG,,,,outpatient,facility,,,5457.00,1637.10,294.16,697.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,592.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,436.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,480.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HEAD EVOLVE COCR 20MM X_496-H420 X_WRIGHT MEDICAL,10317820,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5878.00,1763.40,2280.66,4996.30,,2880.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2468.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2280.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2498.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4408.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2939.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4996.30,,,percent of total billed charges,,,2645.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD EVOLVE COCR 20MM X_496-H420 X_WRIGHT MEDICAL,10317820,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5878.00,1763.40,2468.76,4996.30,,2880.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2468.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2964.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2498.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4408.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2939.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4408.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4996.30,,,percent of total billed charges,,,2703.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM COLLARED HIGH SZ2,10317821,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM COLLARED HIGH SZ2,10317821,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DX FIBERTAK SUTURE ANCHOR ST,10317822,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2542.00,762.60,986.30,2160.70,,,,,,,,,,,,,,,,,,,,986.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1080.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1906.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1271.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.70,,,percent of total billed charges,,,1143.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DX FIBERTAK SUTURE ANCHOR ST,10317822,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2542.00,762.60,1080.35,2160.70,,,,,,,,,,,,,service not payable,,,,,,,1282.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1080.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1906.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1271.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1906.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2160.70,,,percent of total billed charges,,,1169.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS 2.5X24MM X_IH2524 X_STRYKER,10317824,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2938.00,881.40,1139.94,2497.30,,,,,,,,,,,,,,,,,,,,1139.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1248.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2203.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1469.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2497.30,,,percent of total billed charges,,,1322.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS 2.5X24MM X_IH2524 X_STRYKER,10317824,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2938.00,881.40,1248.65,2497.30,,,,,,,,,,,,,service not payable,,,,,,,1481.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1248.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2203.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1469.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2203.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2497.30,,,percent of total billed charges,,,1351.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Nasal Endoscopy diag unilateral or bilateral,10317928,CDM,0490,RC,31231,CPT,,,,,,outpatient,facility,,,500.00,150.00,230.0,3666.78,,500.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,252.20,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,375.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,375.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,425.0,,,percent of total billed charges,,,230.0,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Nasal Endoscopy diag unilateral or bilateral,10317928,CDM,0490,RC,31231,CPT,05151,APC,,,,outpatient,facility,,,500.00,150.00,178.57,427.59,,,,,,,,186.17,,,fee schedule,,,,,,,,,,,,,,,391.64,,,fee schedule,,,178.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",189.89,,,fee schedule,,,427.59,,,fee schedule,,,,,,,,,186.17,,,fee schedule,,,,,,,,,,,,,,,385.97,,,fee schedule,,,,,,,,,186.17,,,fee schedule,,,178.57,,,fee schedule,,,189.89,,,fee schedule,,,,,,,,,186.17,,,fee schedule,,,,,,,,,178.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",189.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.17,,,fee schedule,,,,,,,,,,,,,,,186.17,,,fee schedule,,,,,,,,,188.02,,,fee schedule,,,,,,,,
Nasal Endoscopy diag unilateral or bilateral,10317928,CDM,0490,RC,31231,CPT,249,EAPG,,,,outpatient,facility,,,500.00,150.00,246.43,776.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,660.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,246.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,246.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,272.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,299.40,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TAKERU PTCA BALLOON 1.50X6MM,10317954,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 1.50X12MM,10317955,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.00X8MM,10317956,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.00X12MM,10317957,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.00X20MM,10317958,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.50X8MM,10317959,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.50X12MM,10317960,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.50X15MM,10317961,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAKERU PTCA BALLOON 2.50X20MM,10317962,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.00X8,10317963,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.00X12,10317964,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.00X15,10317965,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.00X21,10317966,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.50X8,10317967,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.50X12,10317968,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.50X15,10317969,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.50X21,10317970,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.75X8,10317971,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.75X12,10317972,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.75X15,10317973,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 2.75X21,10317974,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.00X8,10317975,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.00X12,10317976,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.00X15,10317977,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.00X21,10317978,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.25X8,10317979,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.25X12,10317980,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.25X15,10317981,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.25X21,10317982,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.50X8,10317983,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.50X12,10317984,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.50X15,10317985,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 3.50X21,10317986,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 4.00X8,10317987,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 4.00X12,10317988,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 4.00X15,10317989,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NC TAKERU PTCA BALLOON 4.00X21,10317990,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD BONE T2 UNIV 9MM X_1806-0110 X_STRYKER ORTHOPA,10317992,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2711.00,813.30,1051.87,2304.35,,,,,,,,,,,,,,,,,,,,1051.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1152.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2033.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2304.35,,,percent of total billed charges,,,1219.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD BONE T2 UNIV 9MM X_1806-0110 X_STRYKER ORTHOPA,10317992,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2711.00,813.30,1152.18,2304.35,,,,,,,,,,,,,service not payable,,,,,,,1367.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1152.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2033.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2033.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2304.35,,,percent of total billed charges,,,1247.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 10X83MM,10318003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 10X83MM,10318003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 14X83MM,10318004,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 14X83MM,10318004,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 15X83MM,10318005,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 15X83MM,10318005,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 18X83MM,10318006,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 18X83MM,10318006,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 19X83MM,10318007,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 19X83MM,10318007,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 20X83MM,10318008,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 20X83MM,10318008,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 4MM,10318009,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 4MM,10318009,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 5X83MM,10318010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 5X83MM,10318010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 6X83MM,10318011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 6X83MM,10318011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM COMP MINI 8X83MM,10318012,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM COMP MINI 8X83MM,10318012,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID HUM 36MM PLUS 3,10318013,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID HUM 36MM PLUS 3,10318013,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSHERE 36MM PLUS 6.0MM,10318014,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSHERE 36MM PLUS 6.0MM,10318014,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE 41MM PLUS 3.0MM X_115323 X_ZIMMER US I,10318015,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE 41MM PLUS 3.0MM X_115323 X_ZIMMER US I,10318015,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE 41MM PLUS 6.0MM,10318016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE 41MM PLUS 6.0MM,10318016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP HUM STD OFFSET 40MM,10318017,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP HUM STD OFFSET 40MM,10318017,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP RVS HMRL TRAY 10MM 44MM,10318018,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP RVS HMRL TRAY 10MM 44MM,10318018,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 40MG X_EL-5050 X_MIMEDX,10318021,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 40MG X_EL-5050 X_MIMEDX,10318021,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 100MG X_EL-5125 X_MIMEDX,10318022,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5738.00,1721.40,2226.34,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2226.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4877.30,,,percent of total billed charges,,,2582.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 100MG X_EL-5125 X_MIMEDX,10318022,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2409.96,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 160MG X_EL-5200 X_MIMEDX,10318023,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,8689.00,2606.70,3371.33,7385.65,,4257.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3649.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3371.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3692.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4344.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7385.65,,,percent of total billed charges,,,3910.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 160MG X_EL-5200 X_MIMEDX,10318023,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,8689.00,2606.70,3649.38,7385.65,,4257.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3649.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4382.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3692.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6516.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4344.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6516.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7385.65,,,percent of total billed charges,,,3996.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH OC 6HD 3.6F 1.18MMX135CM,10318024,CDM,0272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,3104.00,931.20,1319.2,2638.40,,1918.27,,,percent of total billed charges,,,,,,,,service not payable,1514.75,,,percent of total billed charges,,,1565.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1319.2,,,percent of total billed charges,,,,,,,,,2328.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1552.0,,,percent of total billed charges,,,,,,,,service not payable,2328.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2638.40,,,percent of total billed charges,,,1427.84,,,percent of total billed charges,,,,,,,,,2017.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2017.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH OC HD 5F 1.18MMX135CM,10318025,CDM,0272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,3104.00,931.20,1319.2,2638.40,,1918.27,,,percent of total billed charges,,,,,,,,service not payable,1514.75,,,percent of total billed charges,,,1565.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1319.2,,,percent of total billed charges,,,,,,,,,2328.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1552.0,,,percent of total billed charges,,,,,,,,service not payable,2328.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2638.40,,,percent of total billed charges,,,1427.84,,,percent of total billed charges,,,,,,,,,2017.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2017.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS TORIC 19.0,10318037,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC 19.0,10318037,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Graft ear cartilage autogenous to nose or ear,10318300,CDM,0450,RC,21235,CPT,,,,,,outpatient,facility,,,11361.00,3408.30,774.0,9656.85,,7021.10,,,percent of total billed charges,,,,,,,,,5544.17,,,percent of total billed charges,,,5730.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8520.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8520.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9656.85,,,percent of total billed charges,,,5226.06,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Graft ear cartilage autogenous to nose or ear,10318300,CDM,0450,RC,21235,CPT,05165,APC,,,,outpatient,facility,,,11361.00,3408.30,2720.69,13029.28,,,,,,,,5672.93,,,fee schedule,,,,,,,,,,,,,,,11933.90,,,fee schedule,,,2720.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",5786.39,,,fee schedule,,,13029.28,,,fee schedule,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,,,,,,,11760.95,,,fee schedule,,,,,,,,,5672.93,,,fee schedule,,,2720.69,,,fee schedule,,,5786.39,,,fee schedule,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,2720.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",5786.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,,,,,,,5672.93,,,fee schedule,,,,,,,,,5729.42,,,fee schedule,,,,,,,,
Graft ear cartilage autogenous to nose or ear,10318300,CDM,0450,RC,21235,CPT,227,EAPG,,,,outpatient,facility,,,11361.00,3408.30,3803.52,9594.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9594.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8155.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3803.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3803.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3803.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4650.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5115.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL LNG RT 10X440MM 125D X_325-440S X_STRYKER ORT,10318496,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL LNG RT 10X440MM 125D X_325-440S X_STRYKER ORT,10318496,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUMB 13X23MMX6D-9MM X_48950136 X_STRYKER,10318497,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUMB 13X23MMX6D-9MM X_48950136 X_STRYKER,10318497,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG THREADED LCKG 12MM X_TPEG-12 X_TRI-MED INC,10318498,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG THREADED LCKG 12MM X_TPEG-12 X_TRI-MED INC,10318498,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP LOCK FT ST 3.5X32MM,10318499,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1251.00,375.30,485.39,1063.35,,,,,,,,,,,,,,,,,,,,485.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,531.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,938.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,625.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1063.35,,,percent of total billed charges,,,562.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP LOCK FT ST 3.5X32MM,10318499,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1251.00,375.30,531.67,1063.35,,,,,,,,,,,,,service not payable,,,,,,,631.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,531.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,938.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,625.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,938.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1063.35,,,percent of total billed charges,,,575.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP LOCK FT ST 3.5X34MM,10318500,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1251.00,375.30,485.39,1063.35,,,,,,,,,,,,,,,,,,,,485.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,531.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,938.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,625.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1063.35,,,percent of total billed charges,,,562.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP LOCK FT ST 3.5X34MM,10318500,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1251.00,375.30,531.67,1063.35,,,,,,,,,,,,,service not payable,,,,,,,631.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,531.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,938.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,625.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,938.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1063.35,,,percent of total billed charges,,,575.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP LOCK FT ST 3.5X36MM,10318501,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1251.00,375.30,485.39,1063.35,,,,,,,,,,,,,,,,,,,,485.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,531.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,938.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,625.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1063.35,,,percent of total billed charges,,,562.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP LOCK FT ST 3.5X36MM,10318501,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1251.00,375.30,531.67,1063.35,,,,,,,,,,,,,service not payable,,,,,,,631.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,531.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,938.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,625.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,938.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1063.35,,,percent of total billed charges,,,575.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL HINGED SM 23MM,10318502,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12439.00,3731.70,4826.33,10573.15,,6095.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4826.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5286.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9329.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6219.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10573.15,,,percent of total billed charges,,,5597.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL HINGED SM 23MM,10318502,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12439.00,3731.70,5224.38,10573.15,,6095.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6274.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5286.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9329.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6219.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9329.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10573.15,,,percent of total billed charges,,,5721.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART G2 SZ1-2 18MM X_71420966 X_SMITH NEPHEW,10318503,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART G2 SZ1-2 18MM X_71420966 X_SMITH NEPHEW,10318503,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH WOLVERINE 2X10MM,10318504,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3324.00,997.20,1412.7,2825.40,,2054.23,,,percent of total billed charges,,,,,,,,service not payable,1622.11,,,percent of total billed charges,,,1676.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,,,,,,,2493.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,2493.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2825.40,,,percent of total billed charges,,,1529.04,,,percent of total billed charges,,,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH WOLVERINE 2.5X10MM,10318505,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3324.00,997.20,1412.7,2825.40,,2054.23,,,percent of total billed charges,,,,,,,,service not payable,1622.11,,,percent of total billed charges,,,1676.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,,,,,,,2493.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,2493.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2825.40,,,percent of total billed charges,,,1529.04,,,percent of total billed charges,,,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH WOLVERINE 3X10MM,10318506,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3324.00,997.20,1412.7,2825.40,,2054.23,,,percent of total billed charges,,,,,,,,service not payable,1622.11,,,percent of total billed charges,,,1676.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,,,,,,,2493.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,2493.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2825.40,,,percent of total billed charges,,,1529.04,,,percent of total billed charges,,,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY FOLEY 14FR W/STAT LK X_899914,10318785,CDM,0272,RC,A4312,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY FOLEY CATH 16FR LATEX FREE X_907316,10318786,CDM,0274,RC,A4315,HCPCS,,,,,,inpatient,facility,,,56.00,16.80,21.73,47.60,,,,,,,,,,,,,,,,,,,,21.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,42.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.60,,,percent of total billed charges,,,25.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY FOLEY CATH 16FR LATEX FREE X_907316,10318786,CDM,0274,RC,A4315,HCPCS,,,,,,outpatient,facility,,,56.00,16.80,23.80,47.60,,,,,,,,,,,,,service not payable,,,,,,,28.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,23.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,42.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,28.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,42.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.60,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EPIDURAL CATHETER X_16339-02,10318794,CDM,0272,RC,C1755,HCPCS,,,,,,outpatient,facility,,,78.00,23.40,33.15,66.30,,48.20,,,percent of total billed charges,,,,,,,,service not payable,38.06,,,percent of total billed charges,,,39.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,39.0,,,percent of total billed charges,,,,,,,,service not payable,58.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,66.30,,,percent of total billed charges,,,35.88,,,percent of total billed charges,,,,,,,,,50.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,50.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY 18FR 30ML X_166818,10318808,CDM,0272,RC,A4344,HCPCS,,,,,,outpatient,facility,,,29.00,8.70,12.32,24.65,,17.92,,,percent of total billed charges,,,,,,,,service not payable,14.15,,,percent of total billed charges,,,14.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12.32,,,percent of total billed charges,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14.5,,,percent of total billed charges,,,,,,,,service not payable,21.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24.65,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,18.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,18.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10318817,CDM,0320,RC,74485,CPT,,,,,,outpatient,facility,,,5457.00,1637.10,139.43,4638.45,,186.86,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,139.43,,,fee schedule,,,2752.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2319.22,,,percent of total billed charges,,,,,,,,,4092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2728.5,,,percent of total billed charges,,,,,,,,,4092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4638.45,,,percent of total billed charges,,,2510.22,,,percent of total billed charges,,,,,,,,,4269.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10318817,CDM,0320,RC,74485,CPT,05373,APC,,,,outpatient,facility,,,5457.00,1637.10,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
SP Exam,10318817,CDM,0320,RC,74485,CPT,474,EAPG,,,,outpatient,facility,,,5457.00,1637.10,294.16,697.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,592.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,436.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,480.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CEMENT BONE LF MIXING MED X_0606-573-000 X_STRYKER,10318883,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT BONE LF MIXING MED X_0606-573-000 X_STRYKER,10318883,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMMOBILIZER SHOULDER LG X_11650007 X_DEROYAL,10318884,CDM,0274,RC,L3650,HCPCS,,,,,,inpatient,facility,,,246.00,73.80,95.45,209.10,,,,,,,,,,,,,,,,,,,,95.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,184.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.10,,,percent of total billed charges,,,110.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER SHOULDER LG X_11650007 X_DEROYAL,10318884,CDM,0274,RC,L3650,HCPCS,,,,,,outpatient,facility,,,246.00,73.80,53.29,209.10,,,,,,,,76.37,,,fee schedule,,,,,,,,,124.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,160.65,,,fee schedule,,,53.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",77.90,,,fee schedule,,,175.40,,,fee schedule,,,,,,,,,76.37,,,fee schedule,,,,,,,,,104.55,,,percent of total billed charges,,Paid in addition to outpatient services ,158.32,,,fee schedule,,,184.5,,,percent of total billed charges,,,76.37,,,fee schedule,,,53.29,,,fee schedule,,,77.90,,,fee schedule,,,123.0,,,percent of total billed charges,,Paid in addition to outpatient services ,76.37,,,fee schedule,,,184.5,,,percent of total billed charges,,,53.29,,,fee schedule,,,77.90,,,fee schedule,,,,,,,,,209.10,,,percent of total billed charges,,,113.16,,,percent of total billed charges,,,,,,,,,,,,,,,76.37,,,fee schedule,,,,,,,,,,,,,,,76.37,,,fee schedule,,,,,,,,,77.14,,,fee schedule,,,,,,,,
CATH 3-WAY 30ML 26F,10318885,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,544.00,163.20,231.20,462.40,,336.19,,,percent of total billed charges,,,,,,,,service not payable,265.47,,,percent of total billed charges,,,274.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,231.20,,,percent of total billed charges,,,,,,,,,408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,272.0,,,percent of total billed charges,,,,,,,,service not payable,408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,462.40,,,percent of total billed charges,,,250.24,,,percent of total billed charges,,,,,,,,,353.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,353.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT PRT 100MG X_AI5125 X_MIMEDX,10318931,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,4574.00,1372.20,1774.71,3887.90,,,,,,,,,,,,,,,,,,,,1774.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.90,,,percent of total billed charges,,,2058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT PRT 100MG X_AI5125 X_MIMEDX,10318931,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,,,,,,,,,,,,service not payable,,,,,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT PRT 100MG X_AI5125 X_MIMEDX,10318931,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,4574.00,1372.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THERMOCOOL SF ST BIDIR TC D F,10318948,CDM,0272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,13393.00,4017.90,5692.02,11384.05,,8276.87,,,percent of total billed charges,,,,,,,,service not payable,6535.78,,,percent of total billed charges,,,6755.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5692.02,,,percent of total billed charges,,,,,,,,,10044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6696.5,,,percent of total billed charges,,,,,,,,service not payable,10044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11384.05,,,percent of total billed charges,,,6160.78,,,percent of total billed charges,,,,,,,,,8705.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8705.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT CORDERE DUR MD X_18-545 X_OCULU-PLASTIK,10318950,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1634.00,490.20,633.99,1388.90,,,,,,,,,,,,,,,,,,,,633.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1225.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,817.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1388.90,,,percent of total billed charges,,,735.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT CORDERE DUR MD X_18-545 X_OCULU-PLASTIK,10318950,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1634.00,490.20,694.45,1388.90,,,,,,,,,,,,,service not payable,,,,,,,824.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,694.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1225.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,817.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1225.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1388.90,,,percent of total billed charges,,,751.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE SZ2 NDL 10 7MM X_AR-7270 X_ARTHREX I,10318953,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE SZ2 NDL 10 7MM X_AR-7270 X_ARTHREX I,10318953,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOGARTY EMBOL 6F 80XM X_120806F X_EDWARDS,10318954,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,276.00,82.80,117.3,234.60,,170.57,,,percent of total billed charges,,,,,,,,service not payable,134.69,,,percent of total billed charges,,,139.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,117.3,,,percent of total billed charges,,,,,,,,,207.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,138.0,,,percent of total billed charges,,,,,,,,service not payable,207.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,234.60,,,percent of total billed charges,,,126.96,,,percent of total billed charges,,,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PROBE FOGARTY 5F 40CM,10318955,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,287.00,86.10,121.97,243.95,,177.37,,,percent of total billed charges,,,,,,,,service not payable,140.06,,,percent of total billed charges,,,144.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.97,,,percent of total billed charges,,,,,,,,,215.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,143.5,,,percent of total billed charges,,,,,,,,service not payable,215.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,,132.02,,,percent of total billed charges,,,,,,,,,186.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,186.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SEALANT HEMOS FLOSEAL 10ML,10318956,CDM,0623,RC,A6250,HCPCS,,,,,,outpatient,facility,,,2055.00,616.50,873.38,1746.75,,1269.99,,,percent of total billed charges,,,,,,,,service not payable,1002.84,,,percent of total billed charges,,,1036.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,873.38,,,percent of total billed charges,,,,,,,,,1541.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,1541.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1746.75,,,percent of total billed charges,,,945.30,,,percent of total billed charges,,,,,,,,,1335.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1335.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 7X28MM X_AR-1370TC X_ARTHREX INC,10318958,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1284.00,385.20,498.19,1091.40,,,,,,,,,,,,,,,,,,,,498.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1091.40,,,percent of total billed charges,,,577.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 7X28MM X_AR-1370TC X_ARTHREX INC,10318958,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1284.00,385.20,545.70,1091.40,,,,,,,,,,,,,service not payable,,,,,,,647.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,963.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1091.40,,,percent of total billed charges,,,590.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 30.5,10318959,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 30.5,10318959,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE ULTRA FASTFIX ST X_7220-1490 X_SMITH,10318961,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1849.00,554.70,717.41,1571.65,,,,,,,,,,,,,,,,,,,,717.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,785.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1386.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,924.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1571.65,,,percent of total billed charges,,,832.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE ULTRA FASTFIX ST X_7220-1490 X_SMITH,10318961,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1849.00,554.70,785.82,1571.65,,,,,,,,,,,,,service not payable,,,,,,,932.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,785.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1386.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,924.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1386.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1571.65,,,percent of total billed charges,,,850.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIGHTROPE SYNDESMOSIS RPR CANN X_AR-8920CDS X_ARTH,10318965,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIGHTROPE SYNDESMOSIS RPR CANN X_AR-8920CDS X_ARTH,10318965,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE 0.5-5MM 15ML X_400052 X_MUSCULOSKELETAL,10318966,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,1760.00,528.00,682.88,1496.0,,,,,,,,,,,,,,,,,,,,682.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1320.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,880.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.0,,,percent of total billed charges,,,792.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE 0.5-5MM 15ML X_400052 X_MUSCULOSKELETAL,10318966,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,1760.00,528.00,748.0,1496.0,,,,,,,,,,,,,service not payable,,,,,,,887.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,748.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1320.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,880.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1320.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1496.0,,,percent of total billed charges,,,809.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE PUTTY SYRINGE 1ML X_038010 X_MUSCULOSKE,10318967,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE PUTTY SYRINGE 1ML X_038010 X_MUSCULOSKE,10318967,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE PUTTY SYRINGE 1ML X_038010 X_MUSCULOSKE,10318967,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,1093.00,327.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THIN WALL 6MMX80CM X_F8006TW X_CR BARD INC,10318968,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,4043.00,1212.90,1568.68,3436.55,,,,,,,,,,,,,,,,,,,,1568.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.55,,,percent of total billed charges,,,1819.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THIN WALL 6MMX80CM X_F8006TW X_CR BARD INC,10318968,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,4043.00,1212.90,1718.27,3436.55,,,,,,,,,,,,,service not payable,,,,,,,2039.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3436.55,,,percent of total billed charges,,,1859.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THIN WALL 8MMX80CM X_F8008TW X_CR BARD INC,10318969,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3781.00,1134.30,1467.03,3213.85,,,,,,,,,,,,,,,,,,,,1467.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2835.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1890.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3213.85,,,percent of total billed charges,,,1701.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THIN WALL 8MMX80CM X_F8008TW X_CR BARD INC,10318969,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3781.00,1134.30,1606.92,3213.85,,,,,,,,,,,,,service not payable,,,,,,,1907.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1606.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2835.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1890.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2835.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3213.85,,,percent of total billed charges,,,1739.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VASCULAR 5-8MMX50CM X_T505-8 X_CR BARD INC,10318970,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2707.00,812.10,1050.32,2300.95,,,,,,,,,,,,,,,,,,,,1050.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2030.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1353.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2300.95,,,percent of total billed charges,,,1218.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VASCULAR 5-8MMX50CM X_T505-8 X_CR BARD INC,10318970,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2707.00,812.10,1150.47,2300.95,,,,,,,,,,,,,service not payable,,,,,,,1365.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2030.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1353.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2030.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2300.95,,,percent of total billed charges,,,1245.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VASCULAR 4-7MMX50CM X_T504-7 X_CR BARD INC,10318971,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2707.00,812.10,1050.32,2300.95,,,,,,,,,,,,,,,,,,,,1050.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2030.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1353.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2300.95,,,percent of total billed charges,,,1218.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VASCULAR 4-7MMX50CM X_T504-7 X_CR BARD INC,10318971,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2707.00,812.10,1150.47,2300.95,,,,,,,,,,,,,service not payable,,,,,,,1365.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2030.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1353.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2030.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2300.95,,,percent of total billed charges,,,1245.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATO POLYAX 6.5X60MM,10319711,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO POLYAX 6.5X60MM,10319711,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLCKG 1.5X16MM X_4941516N X_WRIGHT MEDICAL,10319712,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,528.00,158.40,204.86,448.80,,,,,,,,,,,,,,,,,,,,204.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,396.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,264.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.80,,,percent of total billed charges,,,237.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLCKG 1.5X16MM X_4941516N X_WRIGHT MEDICAL,10319712,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,528.00,158.40,224.40,448.80,,,,,,,,,,,,,service not payable,,,,,,,266.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,224.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,396.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,264.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,396.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,448.80,,,percent of total billed charges,,,242.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLCKG 1.5X18MM X_4941518N X_WRIGHT MEDICAL,10319713,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,528.00,158.40,204.86,448.80,,,,,,,,,,,,,,,,,,,,204.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,396.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,264.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.80,,,percent of total billed charges,,,237.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLCKG 1.5X18MM X_4941518N X_WRIGHT MEDICAL,10319713,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,528.00,158.40,224.40,448.80,,,,,,,,,,,,,service not payable,,,,,,,266.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,224.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,396.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,264.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,396.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,448.80,,,percent of total billed charges,,,242.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.0X10MM X_4942010L X_WRIGHT MEDICAL,10319714,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.0X10MM X_4942010L X_WRIGHT MEDICAL,10319714,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.0X12MM X_4942012L X_WRIGHT MEDICAL,10319715,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.0X12MM X_4942012L X_WRIGHT MEDICAL,10319715,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.0X14MM X_4942014L X_WRIGHT MEDICAL,10319716,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.0X14MM X_4942014L X_WRIGHT MEDICAL,10319716,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLCKG 2.0X14MM X_4942014N X_WRIGHT MEDICAL,10319717,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLCKG 2.0X14MM X_4942014N X_WRIGHT MEDICAL,10319717,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE LGK POLY 2X16MM,10319718,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE LGK POLY 2X16MM,10319718,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE LGK POLY 2X18MM,10319719,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1479.00,443.70,573.85,1257.15,,,,,,,,,,,,,,,,,,,,573.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1257.15,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE LGK POLY 2X18MM,10319719,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1479.00,443.70,628.57,1257.15,,,,,,,,,,,,,service not payable,,,,,,,746.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,628.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1109.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,739.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1257.15,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RNP 25MM X_4920N025 X_WRIGHT MEDICAL,10319720,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4342.00,1302.60,1684.70,3690.70,,,,,,,,,,,,,,,,,,,,1684.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1845.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2171.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3690.70,,,percent of total billed charges,,,1953.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RNP 25MM X_4920N025 X_WRIGHT MEDICAL,10319720,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4342.00,1302.60,1845.35,3690.70,,,,,,,,,,,,,service not payable,,,,,,,2190.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1845.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3256.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2171.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3256.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3690.70,,,percent of total billed charges,,,1997.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COUNTERSINK 1.5MM X_49510121 X_WRIGHT MEDICAL,10319723,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1104.00,331.20,428.35,938.40,,,,,,,,,,,,,,,,,,,,428.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,828.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,938.40,,,percent of total billed charges,,,496.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COUNTERSINK 1.5MM X_49510121 X_WRIGHT MEDICAL,10319723,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1104.00,331.20,469.20,938.40,,,,,,,,,,,,,service not payable,,,,,,,556.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,469.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,828.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,552.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,828.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,938.40,,,percent of total billed charges,,,507.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL AEQUALIS ASC X_MWF122 X_TORNIER INC,10319724,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,262.00,78.60,101.66,222.70,,,,,,,,,,,,,,,,,,,,101.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,196.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.70,,,percent of total billed charges,,,117.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL AEQUALIS ASC X_MWF122 X_TORNIER INC,10319724,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,262.00,78.60,111.35,222.70,,,,,,,,,,,,,service not payable,,,,,,,132.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,111.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,196.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,196.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,222.70,,,percent of total billed charges,,,120.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MMRI Exam,10319903,CDM,0610,RC,C8906,HCPCS,,,,,LT  ,outpatient,facility,,,2330.00,699.00,550.0,1980.5,,700.70,,FormulaCPE:  {Units in Service Type} * 700.70 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 700.70 End FormulaCPE Paid in addition to outpatient services,,,,,,,550.0,,FormulaCPE:  {Units in Service Type} * 550.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 550.00 End FormulaCPE Paid in addition to outpatient services,988.43,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",other,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.0,,,per diem,,,,,,,,,1747.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1831.0,,,per diem,,,,,,,,,1747.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1980.5,,,percent of total billed charges,,,1071.8,,,percent of total billed charges,,,,,,,,,806.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MMRI Exam,10319903,CDM,0610,RC,C8906,HCPCS,05572,APC,,,LT  ,outpatient,facility,,,2330.00,699.00,342.47,786.57,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,720.44,,,fee schedule,,,,,,,,,349.32,,,fee schedule,,,786.57,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,710.0,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,349.32,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,349.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,342.47,,,fee schedule,,,,,,,,,345.88,,,fee schedule,,,,,,,,
MMRI Exam,10319903,CDM,0610,RC,C8906,HCPCS,295,EAPG,,,LT  ,outpatient,facility,,,2330.00,699.00,592.21,1332.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1132.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.21,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,592.21,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,592.21,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,823.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,905.70,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MMRI Exam,10319903,CDM,0610,RC,77049,CPT,,,,,52  ,outpatient,facility,,,1765.00,529.50,528.75,1831.0,,700.70,,,fee schedule,,Paid in addition to outpatient services ,,,,,,service not payable,550.0,,,fee schedule,,Paid in addition to outpatient services ,988.43,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",other,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1556.0,,,per diem,,,,,,,,,1323.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1831.0,,,per diem,,,,,,,,service not payable,1323.75,,,percent of total billed charges,,,855.49,,,fee schedule,,,,,,,,service not payable,,,,,,,1500.25,,,percent of total billed charges,,,811.90,,,percent of total billed charges,,,,,,,,,528.75,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MMRI Exam,10319903,CDM,0610,RC,77049,CPT,295,EAPG,,,52  ,outpatient,facility,,,1765.00,529.50,296.11,666.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,566.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,296.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,296.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,411.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,452.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE VOLAR RT 7H 7PEG X_VLBPR-7-7 X_TRI-MED INC,10320007,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5442.00,1632.60,2111.50,4625.70,,2666.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2285.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2111.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4081.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2721.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4625.70,,,percent of total billed charges,,,2448.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR RT 7H 7PEG X_VLBPR-7-7 X_TRI-MED INC,10320007,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5442.00,1632.60,2285.64,4625.70,,2666.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2285.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2744.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2312.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4081.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2721.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4081.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4625.70,,,percent of total billed charges,,,2503.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4H OLECRANON X_7180-2904 X_SMITH NEPHEW,10320008,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3402.00,1020.60,1319.98,2891.70,,,,,,,,,,,,,,,,,,,,1319.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2551.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1701.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2891.70,,,percent of total billed charges,,,1530.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4H OLECRANON X_7180-2904 X_SMITH NEPHEW,10320008,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3402.00,1020.60,1445.85,2891.70,,,,,,,,,,,,,service not payable,,,,,,,1715.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1445.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2551.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1701.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2551.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2891.70,,,percent of total billed charges,,,1564.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX PL ST 2.7X38MM X_7382-3038 X_SMITH NEPH,10320009,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,117.00,35.10,45.40,99.45,,,,,,,,,,,,,,,,,,,,45.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,87.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.45,,,percent of total billed charges,,,52.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX PL ST 2.7X38MM X_7382-3038 X_SMITH NEPH,10320009,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,117.00,35.10,49.73,99.45,,,,,,,,,,,,,service not payable,,,,,,,59.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,49.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,87.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,58.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,87.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,99.45,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX PL ST 2.7X46MM X_7382-3046 X_SMITH NEPH,10320010,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,117.00,35.10,45.40,99.45,,,,,,,,,,,,,,,,,,,,45.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,87.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.45,,,percent of total billed charges,,,52.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX PL ST 2.7X46MM X_7382-3046 X_SMITH NEPH,10320010,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,117.00,35.10,49.73,99.45,,,,,,,,,,,,,service not payable,,,,,,,59.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,49.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,87.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,58.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,87.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,99.45,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VLP TI 2.0X7MM X_7441-2007N X_SMITH NEPHEW,10320012,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VLP TI 2.0X7MM X_7441-2007N X_SMITH NEPHEW,10320012,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VLP TI 2.0X8MM X_7441-2008N X_SMITH NEPHEW,10320013,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VLP TI 2.0X8MM X_7441-2008N X_SMITH NEPHEW,10320013,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VLP TI 2.0X13MM X_7441-2013N X_SMITH NEPHEW,10320014,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VLP TI 2.0X13MM X_7441-2013N X_SMITH NEPHEW,10320014,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VLP TI 2.0X16MM X_7441-2016N X_SMITH NEPHEW,10320015,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VLP TI 2.0X16MM X_7441-2016N X_SMITH NEPHEW,10320015,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y 2MM 6H X_7444-2010 X_SMITH NEPHEW,10320016,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y 2MM 6H X_7444-2010 X_SMITH NEPHEW,10320016,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE T 2MM 2X6HOLE X_7444-2014 X_SMITH NEPHEW,10320017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE T 2MM 2X6HOLE X_7444-2014 X_SMITH NEPHEW,10320017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIT OVERDRILL MINI 2.1 AO X_7446-2410 X_SMITH NEPH,10320018,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIT OVERDRILL MINI 2.1 AO X_7446-2410 X_SMITH NEPH,10320018,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VOLAR BEARING 5H LT X_VLBPL-5-5 X_TRI-MED IN,10320023,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3721.00,1116.30,1443.75,3162.85,,,,,,,,,,,,,,,,,,,,1443.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3162.85,,,percent of total billed charges,,,1674.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR BEARING 5H LT X_VLBPL-5-5 X_TRI-MED IN,10320023,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3721.00,1116.30,1581.42,3162.85,,,,,,,,,,,,,service not payable,,,,,,,1876.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3162.85,,,percent of total billed charges,,,1711.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 25.0 D 6MM,10320024,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 25.0 D 6MM,10320024,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PLATE 4H DIST LAT FEM RT  X_627634 X_STRYKER ORTHO,10320876,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10430.00,3129.00,4046.84,8865.5,,5110.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4380.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4046.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4432.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7822.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5215.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8865.5,,,percent of total billed charges,,,4693.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4H DIST LAT FEM RT  X_627634 X_STRYKER ORTHO,10320876,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10430.00,3129.00,4380.60,8865.5,,5110.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4380.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5260.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4432.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7822.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5215.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7822.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8865.5,,,percent of total billed charges,,,4797.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT 6X80MM X_608080 X_STRYKER ORTHOPAEDI,10320877,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3477.00,1043.10,1349.08,2955.45,,,,,,,,,,,,,,,,,,,,1349.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2607.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1738.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2955.45,,,percent of total billed charges,,,1564.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT 6X80MM X_608080 X_STRYKER ORTHOPAEDI,10320877,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3477.00,1043.10,1477.72,2955.45,,,,,,,,,,,,,service not payable,,,,,,,1753.8,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1477.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2607.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1738.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2607.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2955.45,,,percent of total billed charges,,,1599.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT NASAL ABSORBABLE LATERA X_LATANI24 X_STRYK,10320878,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4344.00,1303.20,1685.47,3692.40,,,,,,,,,,,,,,,,,,,,1685.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1846.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3258.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2172.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3692.40,,,percent of total billed charges,,,1954.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT NASAL ABSORBABLE LATERA X_LATANI24 X_STRYK,10320878,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4344.00,1303.20,1846.2,3692.40,,,,,,,,,,,,,service not payable,,,,,,,2191.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1846.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3258.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2172.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3258.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3692.40,,,percent of total billed charges,,,1998.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 50X19MM,10320998,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11782.00,3534.60,4571.42,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4571.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10014.70,,,percent of total billed charges,,,5301.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 50X19MM,10320998,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11782.00,3534.60,4948.44,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5942.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10014.70,,,percent of total billed charges,,,5419.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX TIB LCP 7H 420MM,10320999,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3353.00,1005.90,1300.96,2850.05,,,,,,,,,,,,,,,,,,,,1300.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1425.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2514.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1676.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2850.05,,,percent of total billed charges,,,1508.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX TIB LCP 7H 420MM,10320999,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3353.00,1005.90,1425.02,2850.05,,,,,,,,,,,,,service not payable,,,,,,,1691.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1425.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2514.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1676.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2514.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2850.05,,,percent of total billed charges,,,1542.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER VASC 5F 55CM,10321000,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,342.00,102.60,145.35,290.70,,211.36,,,percent of total billed charges,,,,,,,,service not payable,166.90,,,percent of total billed charges,,,172.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,145.35,,,percent of total billed charges,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,171.0,,,percent of total billed charges,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,290.70,,,percent of total billed charges,,,157.32,,,percent of total billed charges,,,,,,,,,222.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,222.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY 26F 16IN 30ML X_0166SI26 X_BARD,10321009,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,57.00,17.10,24.23,48.45,,35.23,,,percent of total billed charges,,,,,,,,service not payable,27.82,,,percent of total billed charges,,,28.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24.23,,,percent of total billed charges,,,,,,,,,42.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,28.5,,,percent of total billed charges,,,,,,,,service not payable,42.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,37.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,37.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY 28F 16IN 5ML X_0166SI28 X_BARD,10321010,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,57.00,17.10,24.23,48.45,,35.23,,,percent of total billed charges,,,,,,,,service not payable,27.82,,,percent of total billed charges,,,28.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24.23,,,percent of total billed charges,,,,,,,,,42.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,28.5,,,percent of total billed charges,,,,,,,,service not payable,42.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,37.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,37.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY 30F 16IN 5ML X_0166SI30 X_BARD,10321011,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,57.00,17.10,24.23,48.45,,35.23,,,percent of total billed charges,,,,,,,,service not payable,27.82,,,percent of total billed charges,,,28.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24.23,,,percent of total billed charges,,,,,,,,,42.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,28.5,,,percent of total billed charges,,,,,,,,service not payable,42.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,37.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,37.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY 26F 16IN 5ML X_0165SI26 X_BARD,10321012,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,51.00,15.30,21.68,43.35,,31.52,,,percent of total billed charges,,,,,,,,service not payable,24.89,,,percent of total billed charges,,,25.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21.68,,,percent of total billed charges,,,,,,,,,38.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25.5,,,percent of total billed charges,,,,,,,,service not payable,38.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43.35,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,33.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,33.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INTERMITTENT 12F 16IN,10321013,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,39.00,11.70,16.57,33.15,,24.10,,,percent of total billed charges,,,,,,,,service not payable,19.03,,,percent of total billed charges,,,19.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,service not payable,29.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,33.15,,,percent of total billed charges,,,17.94,,,percent of total billed charges,,,,,,,,,25.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,25.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INTERMITTENT 24F 16IN,10321014,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,39.00,11.70,16.57,33.15,,24.10,,,percent of total billed charges,,,,,,,,service not payable,19.03,,,percent of total billed charges,,,19.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,service not payable,29.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,33.15,,,percent of total billed charges,,,17.94,,,percent of total billed charges,,,,,,,,,25.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,25.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CONTROL FOLEY 14F 16IN,10321015,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,36.98,73.95,,53.77,,,percent of total billed charges,,,,,,,,service not payable,42.46,,,percent of total billed charges,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.98,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,43.5,,,percent of total billed charges,,,,,,,,service not payable,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CONTROL FOLEY 16F 16IN,10321016,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,36.98,73.95,,53.77,,,percent of total billed charges,,,,,,,,service not payable,42.46,,,percent of total billed charges,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.98,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,43.5,,,percent of total billed charges,,,,,,,,service not payable,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CONTROL FOLEY 20F 16IN,10321017,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,36.98,73.95,,53.77,,,percent of total billed charges,,,,,,,,service not payable,42.46,,,percent of total billed charges,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.98,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,43.5,,,percent of total billed charges,,,,,,,,service not payable,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CONTROL FOLEY 22F 16IN,10321018,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,36.98,73.95,,53.77,,,percent of total billed charges,,,,,,,,service not payable,42.46,,,percent of total billed charges,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.98,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,43.5,,,percent of total billed charges,,,,,,,,service not payable,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CONTROL FOLEY 24F 16IN,10321019,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,36.98,73.95,,53.77,,,percent of total billed charges,,,,,,,,service not payable,42.46,,,percent of total billed charges,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.98,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,43.5,,,percent of total billed charges,,,,,,,,service not payable,65.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,56.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY LUBRICATH 22F 16IN X_6003L22 X_BARD,10321020,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,156.00,46.80,66.30,132.60,,96.41,,,percent of total billed charges,,,,,,,,service not payable,76.13,,,percent of total billed charges,,,78.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,66.30,,,percent of total billed charges,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,78.0,,,percent of total billed charges,,,,,,,,service not payable,117.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,132.60,,,percent of total billed charges,,,71.76,,,percent of total billed charges,,,,,,,,,101.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,101.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER FOLEY LUBRICATH 24F 16IN X_6003L24 X_BARD,10321021,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,156.00,46.80,66.30,132.60,,96.41,,,percent of total billed charges,,,,,,,,service not payable,76.13,,,percent of total billed charges,,,78.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,66.30,,,percent of total billed charges,,,,,,,,,117.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,78.0,,,percent of total billed charges,,,,,,,,service not payable,117.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,132.60,,,percent of total billed charges,,,71.76,,,percent of total billed charges,,,,,,,,,101.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,101.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 11.5MMX42CM META-TAN L X_71649742 X_SMITH NEP,10321025,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10900.00,3270.00,4229.20,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4229.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9265.0,,,percent of total billed charges,,,4905.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 11.5MMX42CM META-TAN L X_71649742 X_SMITH NEP,10321025,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10900.00,3270.00,4578.0,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5497.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9265.0,,,percent of total billed charges,,,5014.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG KIT 85X80MM X_71642685 X_SMITH NEPHEW,10321026,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG KIT 85X80MM X_71642685 X_SMITH NEPHEW,10321026,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP SZ6 26X120MM X_1601-06132 X_STRYKER ORTHO,10321423,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP SZ6 26X120MM X_1601-06132 X_STRYKER ORTHO,10321423,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE BARE X_22440-31 X_ABBOTT VASCULAR,10321425,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.23,558.45,,406.03,,,percent of total billed charges,,,,,,,,service not payable,320.62,,,percent of total billed charges,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.23,,,percent of total billed charges,,,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT XACT CAROTID 9X30MM X_82088-01 X_ABBOTT VASC,10321426,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,6639.00,1991.70,2575.93,5643.15,,3253.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2788.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2575.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2821.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5643.15,,,percent of total billed charges,,,2987.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT XACT CAROTID 9X30MM X_82088-01 X_ABBOTT VASC,10321426,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2788.38,5643.15,,3253.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2788.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BIFURCATED 18-9MMX50CM X_SBT1802D X_GORE MED,10321427,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3745.00,1123.50,1453.06,3183.25,,,,,,,,,,,,,,,,,,,,1453.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1591.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2808.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1872.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3183.25,,,percent of total billed charges,,,1685.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BIFURCATED 18-9MMX50CM X_SBT1802D X_GORE MED,10321427,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3745.00,1123.50,1591.62,3183.25,,,,,,,,,,,,,service not payable,,,,,,,1888.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1591.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2808.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1872.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2808.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3183.25,,,percent of total billed charges,,,1722.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT EXCLUDER 31X14.5MM,10321428,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24880.00,7464.00,9653.44,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9653.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21148.0,,,percent of total billed charges,,,11196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT EXCLUDER 31X14.5MM,10321428,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24880.00,7464.00,10449.6,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12549.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21148.0,,,percent of total billed charges,,,11444.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL BONE FEMORAL T2 13X360MM X_1826-1336S X_STRYK,10321430,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6041.00,1812.30,2343.91,5134.85,,2960.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2537.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2343.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2567.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4530.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5134.85,,,percent of total billed charges,,,2718.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL BONE FEMORAL T2 13X360MM X_1826-1336S X_STRYK,10321430,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6041.00,1812.30,2537.22,5134.85,,2960.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2537.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3047.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2567.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4530.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4530.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5134.85,,,percent of total billed charges,,,2778.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 19.0 D 6MM,10321431,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 19.0 D 6MM,10321431,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
FNA biopsy including US guidance ea addtl lesion,10321485,CDM,0490,RC,10006,CPT,,,,,,outpatient,facility,,,882.00,264.60,405.72,2912.34,,882.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,444.88,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,661.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,661.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,749.70,,,percent of total billed charges,,,405.72,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FNA biopsy including US guidance ea addtl lesion,10321485,CDM,0490,RC,10006,CPT,2,EAPG,,,,outpatient,facility,,,882.00,264.60,882.0,1808.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1808.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1537.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,882.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,882.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,882.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,933.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1027.09,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE VOLAR RT 5H 5PEG X_VLBPR-5-5 X_TRI-MED INC,10321569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3721.00,1116.30,1443.75,3162.85,,,,,,,,,,,,,,,,,,,,1443.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3162.85,,,percent of total billed charges,,,1674.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VOLAR RT 5H 5PEG X_VLBPR-5-5 X_TRI-MED INC,10321569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3721.00,1116.30,1581.42,3162.85,,,,,,,,,,,,,service not payable,,,,,,,1876.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2790.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1860.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2790.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3162.85,,,percent of total billed charges,,,1711.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG THREADED LCKG 10MM X_TPEG-10 X_,10321571,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG THREADED LCKG 10MM X_TPEG-10 X_,10321571,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 20.5,10321572,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 20.5,10321572,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE WRIST SPANNING SHORT X_706-1170N-S X_ACUMED,10321642,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3327.00,998.10,1290.88,2827.95,,,,,,,,,,,,,,,,,,,,1290.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2495.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1663.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2827.95,,,percent of total billed charges,,,1497.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE WRIST SPANNING SHORT X_706-1170N-S X_ACUMED,10321642,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3327.00,998.10,1413.97,2827.95,,,,,,,,,,,,,service not payable,,,,,,,1678.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1413.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2495.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1663.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2495.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2827.95,,,percent of total billed charges,,,1530.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX NON-LCKG 2.7X8MM X_30-0343-S X_ACUMED,10321643,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,427.00,128.10,165.68,362.95,,,,,,,,,,,,,,,,,,,,165.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,192.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX NON-LCKG 2.7X8MM X_30-0343-S X_ACUMED,10321643,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,427.00,128.10,181.47,362.95,,,,,,,,,,,,,service not payable,,,,,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,320.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD EVOLVE COCR 18MM X_496H218 X_WRIGHT MEDICAL,10321645,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5878.00,1763.40,2280.66,4996.30,,2880.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2468.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2280.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2498.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4408.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2939.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4996.30,,,percent of total billed charges,,,2645.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD EVOLVE COCR 18MM X_496H218 X_WRIGHT MEDICAL,10321645,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5878.00,1763.40,2468.76,4996.30,,2880.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2468.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2964.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2498.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4408.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2939.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4408.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4996.30,,,percent of total billed charges,,,2703.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER LIP ALTRX 36 X 62MM,10321646,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER LIP ALTRX 36 X 62MM,10321646,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 7X60X130,10321647,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUMB 12X23MMX6D-9MM X_48950126 X_STRYKER,10321648,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUMB 12X23MMX6D-9MM X_48950126 X_STRYKER,10321648,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Neuroplasty and/or transposition cranial nerve,10321672,CDM,0490,RC,64716,CPT,,,,,,outpatient,facility,,,4968.00,1490.40,2285.28,5076.0,,4968.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,2505.86,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,3726.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,3726.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4222.80,,,percent of total billed charges,,,2285.28,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Neuroplasty and/or transposition cranial nerve,10321672,CDM,0490,RC,64716,CPT,05431,APC,,,,outpatient,facility,,,4968.00,1490.40,1796.21,4300.98,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,3939.40,,,fee schedule,,,1796.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1910.09,,,fee schedule,,,4300.98,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,3882.30,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,1796.21,,,fee schedule,,,1910.09,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,1796.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1910.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,1891.29,,,fee schedule,,,,,,,,
Neuroplasty and/or transposition cranial nerve,10321672,CDM,0490,RC,64716,CPT,218,EAPG,,,,outpatient,facility,,,4968.00,1490.40,4968.0,10018.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10018.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8515.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4968.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4968.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4968.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5317.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5848.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SURFACE GLDNG VEGA PS T310MM X_NX130 X_AESCULAP,10321730,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE GLDNG VEGA PS T310MM X_NX130 X_AESCULAP,10321730,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PONTO X_SQ00987 X_OTICON MEDICAL,10321732,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,51693.00,15507.90,20056.88,43939.05,,25329.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21711.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,20056.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21969.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38769.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25846.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43939.05,,,percent of total billed charges,,,23261.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PONTO X_SQ00987 X_OTICON MEDICAL,10321732,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,51693.00,15507.90,21711.06,43939.05,,25329.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21711.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,26073.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21969.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38769.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25846.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38769.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43939.05,,,percent of total billed charges,,,23778.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIBULA DISTAL 4H 79MM,10321733,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIBULA DISTAL 4H 79MM,10321733,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GTT Fasting Glucose,10322033,CDM,0300,RC,82947,CPT,,,,,,outpatient,facility,,,31.00,9.30,3.73,26.35,,16.67,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,3.85,,,fee schedule,,,12.44,,,fee schedule,,,8.20,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,8.14,,,fee schedule,,,3.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3.93,,,fee schedule,,,8.88,,,fee schedule,,,,,,,,,3.85,,,fee schedule,,,,,,,,,5.05,,,fee schedule,,,8.02,,,fee schedule,,,23.25,,,percent of total billed charges,,,3.85,,,fee schedule,,,3.73,,,fee schedule,,,3.93,,,fee schedule,,,5.94,,,fee schedule,,,3.85,,,fee schedule,,,23.25,,,percent of total billed charges,,,3.73,,,fee schedule,,,3.93,,,fee schedule,,,,,,,,,26.35,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,4.32,,,fee schedule,,,3.85,,,fee schedule,,,,,,,,,3.81,,,fee schedule,,,3.85,,,fee schedule,,,,,,,,,3.89,,,fee schedule,,,,,,,,
GTT Fasting Glucose,10322033,CDM,0300,RC,82947,CPT,402,EAPG,,,,outpatient,facility,,,31.00,9.30,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GTT Post 2 Hour Glucose,10322034,CDM,0300,RC,82950,CPT,,,,,,outpatient,facility,,,43.00,12.90,4.51,36.55,,20.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.65,,,fee schedule,,,15.05,,,fee schedule,,,9.90,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,9.83,,,fee schedule,,,4.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.74,,,fee schedule,,,10.73,,,fee schedule,,,,,,,,,4.65,,,fee schedule,,,,,,,,,6.31,,,fee schedule,,,9.69,,,fee schedule,,,32.25,,,percent of total billed charges,,,4.65,,,fee schedule,,,4.51,,,fee schedule,,,4.74,,,fee schedule,,,7.43,,,fee schedule,,,4.65,,,fee schedule,,,32.25,,,percent of total billed charges,,,4.51,,,fee schedule,,,4.74,,,fee schedule,,,,,,,,,36.55,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,5.23,,,fee schedule,,,4.65,,,fee schedule,,,,,,,,,4.61,,,fee schedule,,,4.65,,,fee schedule,,,,,,,,,4.70,,,fee schedule,,,,,,,,
GTT Post 2 Hour Glucose,10322034,CDM,0300,RC,82950,CPT,402,EAPG,,,,outpatient,facility,,,43.00,12.90,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OB 3 Hr GTT Post 2 Hour Glucose,10322077,CDM,0300,RC,82951,CPT,,,,,,outpatient,facility,,,100.00,30.00,12.23,85.0,,54.71,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.61,,,fee schedule,,,40.82,,,fee schedule,,,26.84,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.64,,,fee schedule,,,12.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.86,,,fee schedule,,,29.09,,,fee schedule,,,,,,,,,12.61,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.25,,,fee schedule,,,75.0,,,percent of total billed charges,,,12.61,,,fee schedule,,,12.23,,,fee schedule,,,12.86,,,fee schedule,,,19.32,,,fee schedule,,,12.61,,,fee schedule,,,75.0,,,percent of total billed charges,,,12.23,,,fee schedule,,,12.86,,,fee schedule,,,,,,,,,85.0,,,percent of total billed charges,,,46.0,,,percent of total billed charges,,,,,,,,,14.16,,,fee schedule,,,12.61,,,fee schedule,,,,,,,,,12.48,,,fee schedule,,,12.61,,,fee schedule,,,,,,,,,12.74,,,fee schedule,,,,,,,,
OB 3 Hr GTT Post 2 Hour Glucose,10322077,CDM,0300,RC,82951,CPT,400,EAPG,,,,outpatient,facility,,,100.00,30.00,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OB 3 Hr GTT Post 3 Hour Glucose,10322078,CDM,0300,RC,82952,CPT,,,,,,outpatient,facility,,,25.00,7.50,3.72,21.25,,10.65,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,3.84,,,fee schedule,,,7.95,,,fee schedule,,,8.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,8.11,,,fee schedule,,,3.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3.92,,,fee schedule,,,8.86,,,fee schedule,,,,,,,,,3.84,,,fee schedule,,,,,,,,,5.05,,,fee schedule,,,8.0,,,fee schedule,,,18.75,,,percent of total billed charges,,,3.84,,,fee schedule,,,3.72,,,fee schedule,,,3.92,,,fee schedule,,,5.94,,,fee schedule,,,3.84,,,fee schedule,,,18.75,,,percent of total billed charges,,,,,,,,,3.92,,,fee schedule,,,,,,,,,21.25,,,percent of total billed charges,,,11.5,,,percent of total billed charges,,,,,,,,,4.31,,,fee schedule,,,3.84,,,fee schedule,,,,,,,,,3.80,,,fee schedule,,,3.84,,,fee schedule,,,,,,,,,3.88,,,fee schedule,,,,,,,,
OB 3 Hr GTT Post 3 Hour Glucose,10322078,CDM,0300,RC,82952,CPT,402,EAPG,,,,outpatient,facility,,,25.00,7.50,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GUIDEWIRE STR TIP .014IN 182CM,10322119,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,873.00,261.90,371.02,742.05,,539.51,,,percent of total billed charges,,,,,,,,service not payable,426.02,,,percent of total billed charges,,,440.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.02,,,percent of total billed charges,,,,,,,,,654.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,436.5,,,percent of total billed charges,,,,,,,,service not payable,654.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,742.05,,,percent of total billed charges,,,401.58,,,percent of total billed charges,,,,,,,,,567.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,567.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE EXPANDABLE 10MM 10X24MM,10322120,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE EXPANDABLE 10MM 10X24MM,10322120,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OCCIPUT MINI OASYS MIDLINE X_48551048 X_STRY,10322122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OCCIPUT MINI OASYS MIDLINE X_48551048 X_STRY,10322122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 4.0X10MM X_48554410 X_STRYKER,10322123,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,908.00,272.40,352.30,771.80,,,,,,,,,,,,,,,,,,,,352.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,681.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.80,,,percent of total billed charges,,,408.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 4.0X10MM X_48554410 X_STRYKER,10322123,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,908.00,272.40,385.90,771.80,,,,,,,,,,,,,service not payable,,,,,,,458.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,681.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,681.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,771.80,,,percent of total billed charges,,,417.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 4.0X8MM X_48554408 X_STRYKER,10322124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,908.00,272.40,352.30,771.80,,,,,,,,,,,,,,,,,,,,352.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,681.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.80,,,percent of total billed charges,,,408.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 4.0X8MM X_48554408 X_STRYKER,10322124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,908.00,272.40,385.90,771.80,,,,,,,,,,,,,service not payable,,,,,,,458.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,681.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,454.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,681.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,771.80,,,percent of total billed charges,,,417.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT FLUENCY 7X80MM X_FEM07080 X_BARD PERIP,10322125,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7131.00,2139.30,2766.83,6061.35,,3494.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2995.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2766.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3030.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5348.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6061.35,,,percent of total billed charges,,,3208.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT FLUENCY 7X80MM X_FEM07080 X_BARD PERIP,10322125,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7131.00,2139.30,2995.02,6061.35,,3494.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2995.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3596.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3030.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5348.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6061.35,,,percent of total billed charges,,,3280.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT MAIN BODY 23X12MMX16CM X_RLT231216 X_GORE ME,10322127,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24880.00,7464.00,9653.44,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9653.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21148.0,,,percent of total billed charges,,,11196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT MAIN BODY 23X12MMX16CM X_RLT231216 X_GORE ME,10322127,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24880.00,7464.00,10449.6,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12549.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21148.0,,,percent of total billed charges,,,11444.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT CONT LEG 12MM 12CM,10322129,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,20404.00,6121.20,7916.75,17343.40,,9997.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8569.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7916.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8671.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10202.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17343.40,,,percent of total billed charges,,,9181.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT CONT LEG 12MM 12CM,10322129,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,20404.00,6121.20,8569.68,17343.40,,9997.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8569.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10291.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8671.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10202.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15303.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17343.40,,,percent of total billed charges,,,9385.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR TRANSVERSE 60MM X_48551071 X_STRYKER,10322131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR TRANSVERSE 60MM X_48551071 X_STRYKER,10322131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR TRANSVERSE 40MM X_48551072 X_STRYKER,10322132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR TRANSVERSE 40MM X_48551072 X_STRYKER,10322132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT SM HEX 4.0X30MM,10322133,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT SM HEX 4.0X30MM,10322133,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINAL POST 3.5X80MM,10322464,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINAL POST 3.5X80MM,10322464,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM TI 14X28MMX6DEG X_48955146 X_STRYKER,10322466,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM TI 14X28MMX6DEG X_48955146 X_STRYKER,10322466,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 24.5D 6MM,10322467,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 24.5D 6MM,10322467,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LINER HIP NEUTRAL 10D 28X50MM,10322469,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14458.00,4337.40,5609.70,12289.30,,7084.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6072.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5609.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6144.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10843.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12289.30,,,percent of total billed charges,,,6506.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP NEUTRAL 10D 28X50MM,10322469,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14458.00,4337.40,6072.36,12289.30,,7084.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6072.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7292.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6144.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10843.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10843.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12289.30,,,percent of total billed charges,,,6650.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING MEPILEX BRDR 4X6IN X_496300 X_MOLNLYCKE H,10322558,CDM,0272,RC,A6212,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,41.65,,30.28,,,percent of total billed charges,,,,,,,,service not payable,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,service not payable,36.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,31.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP 2.3X30MM X_ TRX2.3-30 X_TRI-MED INC,10322559,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,454.00,136.20,176.15,385.90,,,,,,,,,,,,,,,,,,,,176.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,,204.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP 2.3X30MM X_ TRX2.3-30 X_TRI-MED INC,10322559,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,454.00,136.20,192.95,385.90,,,,,,,,,,,,,service not payable,,,,,,,229.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,340.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,,208.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK POW TI 6MM X_AR-8953-06 X_ARTHREX INC,10322560,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK POW TI 6MM X_AR-8953-06 X_ARTHREX INC,10322560,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTACHMENT ROD EXTERNAL FIX LG X_390.003 X_STRYKER,10322561,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2347.00,704.10,910.64,1994.95,,,,,,,,,,,,,,,,,,,,910.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1760.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1173.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1994.95,,,percent of total billed charges,,,1056.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTACHMENT ROD EXTERNAL FIX LG X_390.003 X_STRYKER,10322561,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2347.00,704.10,997.48,1994.95,,,,,,,,,,,,,service not payable,,,,,,,1183.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,997.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1760.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1173.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1760.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1994.95,,,percent of total billed charges,,,1079.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP PIN BONE EXTERNAL FIX LG X_390.002 X_STRYKER,10322562,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4187.00,1256.10,1624.56,3558.95,,,,,,,,,,,,,,,,,,,,1624.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1779.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3140.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2093.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3558.95,,,percent of total billed charges,,,1884.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP PIN BONE EXTERNAL FIX LG X_390.002 X_STRYKER,10322562,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4187.00,1256.10,1779.47,3558.95,,,,,,,,,,,,,service not payable,,,,,,,2111.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1779.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3140.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2093.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3140.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3558.95,,,percent of total billed charges,,,1926.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PST STB SZ 8 10MM X_1516-50-810 X_DEPUY,10322711,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PST STB SZ 8 10MM X_1516-50-810 X_DEPUY,10322711,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Immature Platelet Fraction - IPF,10322713,CDM,0300,RC,85055,CPT,,,,,,outpatient,facility,,,77.00,23.10,33.95,80.77,,69.38,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,35.03,,,fee schedule,,,51.77,,,fee schedule,,,74.53,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,73.98,,,fee schedule,,,33.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.73,,,fee schedule,,,80.77,,,fee schedule,,,,,,,,,35.03,,,fee schedule,,,,,,,,,45.92,,,fee schedule,,,72.91,,,fee schedule,,,57.75,,,percent of total billed charges,,,35.03,,,fee schedule,,,33.95,,,fee schedule,,,35.73,,,fee schedule,,,54.0,,,fee schedule,,,35.03,,,fee schedule,,,57.75,,,percent of total billed charges,,,,,,,,,35.73,,,fee schedule,,,,,,,,,65.45,,,percent of total billed charges,,,35.42,,,percent of total billed charges,,,,,,,,,39.31,,,fee schedule,,,35.03,,,fee schedule,,,,,,,,,34.67,,,fee schedule,,,35.03,,,fee schedule,,,,,,,,,35.38,,,fee schedule,,,,,,,,
Immature Platelet Fraction - IPF,10322713,CDM,0300,RC,85055,CPT,407,EAPG,,,,outpatient,facility,,,77.00,23.10,29.94,128.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,108.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,29.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,29.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,85.93,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Aerobic MALDI ID,10322759,CDM,0300,RC,87077,CPT,,,,,,outpatient,facility,,,97.00,29.10,7.68,82.45,,34.35,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.92,,,fee schedule,,,25.63,,,fee schedule,,,16.85,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,16.73,,,fee schedule,,,7.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.08,,,fee schedule,,,18.26,,,fee schedule,,,,,,,,,7.92,,,fee schedule,,,,,,,,,10.54,,,fee schedule,,,16.48,,,fee schedule,,,72.75,,,percent of total billed charges,,,7.92,,,fee schedule,,,7.68,,,fee schedule,,,8.08,,,fee schedule,,,12.39,,,fee schedule,,,7.92,,,fee schedule,,,72.75,,,percent of total billed charges,,,,,,,,,8.08,,,fee schedule,,,,,,,,,82.45,,,percent of total billed charges,,,44.62,,,percent of total billed charges,,,,,,,,,8.89,,,fee schedule,,,7.92,,,fee schedule,,,,,,,,,7.84,,,fee schedule,,,7.92,,,fee schedule,,,,,,,,,8.0,,,fee schedule,,,,,,,,
Aerobic MALDI ID,10322759,CDM,0300,RC,87077,CPT,396,EAPG,,,,outpatient,facility,,,97.00,29.10,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Immature Platelet Fraction - IPF-Platelet,10322782,CDM,0300,RC,85049,CPT,,,,,,outpatient,facility,,,40.00,12.00,4.26,34.0,,19.02,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.39,,,fee schedule,,,14.19,,,fee schedule,,,9.34,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,9.27,,,fee schedule,,,4.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.48,,,fee schedule,,,10.12,,,fee schedule,,,,,,,,,4.39,,,fee schedule,,,,,,,,,5.89,,,fee schedule,,,9.14,,,fee schedule,,,30.0,,,percent of total billed charges,,,4.39,,,fee schedule,,,4.26,,,fee schedule,,,4.48,,,fee schedule,,,6.93,,,fee schedule,,,4.39,,,fee schedule,,,30.0,,,percent of total billed charges,,,,,,,,,4.48,,,fee schedule,,,,,,,,,34.0,,,percent of total billed charges,,,18.40,,,percent of total billed charges,,,,,,,,,4.93,,,fee schedule,,,4.39,,,fee schedule,,,,,,,,,4.35,,,fee schedule,,,4.39,,,fee schedule,,,,,,,,,4.43,,,fee schedule,,,,,,,,
Immature Platelet Fraction - IPF-Platelet,10322782,CDM,0300,RC,85049,CPT,408,EAPG,,,,outpatient,facility,,,40.00,12.00,6.99,27.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.99,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,22.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,25.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Muscle myocutaneous or fasciocutaneous flap head,10322847,CDM,0490,RC,15733,CPT,,,,,,outpatient,facility,,,8424.00,2527.20,3875.04,7160.40,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,4249.07,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,6318.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,6318.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7160.40,,,percent of total billed charges,,,3875.04,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Muscle myocutaneous or fasciocutaneous flap head,10322847,CDM,0490,RC,15733,CPT,05055,APC,,,,outpatient,facility,,,8424.00,2527.20,3367.45,8063.30,,,,,,,,3510.74,,,fee schedule,,,,,,,,,,,,,,,7385.41,,,fee schedule,,,3367.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3580.95,,,fee schedule,,,8063.30,,,fee schedule,,,,,,,,,3510.74,,,fee schedule,,,,,,,,,,,,,,,7278.37,,,fee schedule,,,,,,,,,3510.74,,,fee schedule,,,3367.45,,,fee schedule,,,3580.95,,,fee schedule,,,,,,,,,3510.74,,,fee schedule,,,,,,,,,3367.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3580.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3510.74,,,fee schedule,,,,,,,,,,,,,,,3510.74,,,fee schedule,,,,,,,,,3545.71,,,fee schedule,,,,,,,,
Muscle myocutaneous or fasciocutaneous flap head,10322847,CDM,0490,RC,15733,CPT,56,EAPG,,,,outpatient,facility,,,8424.00,2527.20,2726.14,4906.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4906.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4170.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2726.14,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2998.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
AUGMT POST FEM SZ2 8MM LT,10323045,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT POST FEM SZ2 8MM LT,10323045,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
T-HANDLE OMEGA PLUS X_704020 X_STRYKER ORTHOPAEDIC,10323047,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2457.00,737.10,953.32,2088.45,,,,,,,,,,,,,,,,,,,,953.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1044.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1842.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2088.45,,,percent of total billed charges,,,1105.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
T-HANDLE OMEGA PLUS X_704020 X_STRYKER ORTHOPAEDIC,10323047,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2457.00,737.10,1044.22,2088.45,,,,,,,,,,,,,service not payable,,,,,,,1239.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1044.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1842.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1842.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2088.45,,,percent of total billed charges,,,1130.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWVLK 4.75X19.1MM X_AR-2324PSLC X_ARTHREX I,10323049,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2049.00,614.70,795.01,1741.65,,,,,,,,,,,,,,,,,,,,795.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.65,,,percent of total billed charges,,,922.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWVLK 4.75X19.1MM X_AR-2324PSLC X_ARTHREX I,10323049,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2049.00,614.70,870.82,1741.65,,,,,,,,,,,,,service not payable,,,,,,,1033.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,870.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1536.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1024.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1536.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1741.65,,,percent of total billed charges,,,942.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MEDIAL 16H X_PL-LEM16 X_ACUMED,10323050,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5874.00,1762.20,2279.11,4992.90,,2878.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2467.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2279.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2496.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4405.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2937.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4992.90,,,percent of total billed charges,,,2643.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MEDIAL 16H X_PL-LEM16 X_ACUMED,10323050,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5874.00,1762.20,2467.08,4992.90,,2878.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2467.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2962.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2496.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4405.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2937.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4405.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4992.90,,,percent of total billed charges,,,2702.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Trauma Team Activation,10323092,CDM,0683,RC,G0390,HCPCS,,,,,,outpatient,facility,,,2966.00,889.80,1260.55,2521.10,,1832.99,,,percent of total billed charges,,,,,,,,,1447.41,,,percent of total billed charges,,,1496.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1260.55,,,percent of total billed charges,,,,,,,,,2224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1483.0,,,percent of total billed charges,,,,,,,,,2224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2521.10,,,percent of total billed charges,,,1364.36,,,percent of total billed charges,,,,,,,,,1927.90,,,percent of total billed charges,,,,,,,,,,,,,,,1927.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
Trauma Team Activation,10323092,CDM,0683,RC,G0390,HCPCS,05045,APC,,,,outpatient,facility,,,2966.00,889.80,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Trauma Team Activation,10323092,CDM,0683,RC,G0390,HCPCS,852,EAPG,,,,outpatient,facility,,,2966.00,889.80,254.45,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Respiratory Viral Panel (RVP) PCR,10323100,CDM,0300,RC,87632,CPT,,,,,,outpatient,facility,,,1039.00,311.70,207.16,906.96,,906.96,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,213.70,,,fee schedule,,,676.75,,,fee schedule,,,454.77,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,451.38,,,fee schedule,,,207.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",217.97,,,fee schedule,,,492.82,,,fee schedule,,,,,,,,,213.70,,,fee schedule,,,,,,,,,280.57,,,fee schedule,,,444.84,,,fee schedule,,,779.25,,,percent of total billed charges,,,213.70,,,fee schedule,,,207.16,,,fee schedule,,,217.97,,,fee schedule,,,329.97,,,fee schedule,,,213.70,,,fee schedule,,,779.25,,,percent of total billed charges,,,,,,,,,217.97,,,fee schedule,,,,,,,,,883.15,,,percent of total billed charges,,,477.94,,,percent of total billed charges,,,,,,,,,239.87,,,fee schedule,,,213.70,,,fee schedule,,,,,,,,,211.52,,,fee schedule,,,213.70,,,fee schedule,,,,,,,,,215.84,,,fee schedule,,,,,,,,
Respiratory Viral Panel (RVP) PCR,10323100,CDM,0300,RC,87632,CPT,388,EAPG,,,,outpatient,facility,,,1039.00,311.70,202.12,322.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,273.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,202.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,222.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SURFACE GLIDING VEGA PS 14MM X_NX122 X_DEPUY,10323162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE GLIDING VEGA PS 14MM X_NX122 X_DEPUY,10323162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BIASED 3.5X28MM X_48552328 X_STRYKER MEDICAL,10323163,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIASED 3.5X28MM X_48552328 X_STRYKER MEDICAL,10323163,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY 3.5X14 X_48558314 X_STRYKER MEDICAL COR,10323164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY 3.5X14 X_48558314 X_STRYKER MEDICAL COR,10323164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Curettage postpartum,10323222,CDM,0490,RC,59160,CPT,,,,,,outpatient,facility,,,5993.00,1797.90,2756.78,5993.0,,5993.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,3022.87,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,4494.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,4494.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5094.05,,,percent of total billed charges,,,2756.78,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Curettage postpartum,10323222,CDM,0490,RC,59160,CPT,05414,APC,,,,outpatient,facility,,,5993.00,1797.90,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Curettage postpartum,10323222,CDM,0490,RC,59160,CPT,205,EAPG,,,,outpatient,facility,,,5993.00,1797.90,2464.07,5913.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5913.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5026.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2464.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2464.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2464.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2866.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3152.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CAGE PL 8X28MM0D-9MM X_48952080 X_STRYKER SPINE,10323238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PL 8X28MM0D-9MM X_48952080 X_STRYKER SPINE,10323238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM PICO WOUND VAC X_66800953 X_SMITH NEPHEW,10323239,CDM,0272,RC,A6550,HCPCS,,,,,,outpatient,facility,,,1203.00,360.90,511.27,1022.55,,743.45,,,percent of total billed charges,,,,,,,,service not payable,587.06,,,percent of total billed charges,,,606.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,511.27,,,percent of total billed charges,,,,,,,,,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,601.5,,,percent of total billed charges,,,,,,,,service not payable,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1022.55,,,percent of total billed charges,,,553.38,,,percent of total billed charges,,,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FIBULOCK IMPLANT,10323240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FIBULOCK IMPLANT,10323240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FIB RT 3.8X130MM X_FIB38130R X_ARTHREX INC,10323241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FIB RT 3.8X130MM X_FIB38130R X_ARTHREX INC,10323241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 5H TUBULAR LCKG X_AR-8943T-05 X_ARTHREX INC,10323244,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1284.00,385.20,498.19,1091.40,,,,,,,,,,,,,,,,,,,,498.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1091.40,,,percent of total billed charges,,,577.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 5H TUBULAR LCKG X_AR-8943T-05 X_ARTHREX INC,10323244,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1284.00,385.20,545.70,1091.40,,,,,,,,,,,,,service not payable,,,,,,,647.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,545.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,963.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,642.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,963.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1091.40,,,percent of total billed charges,,,590.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM PROX LAT LFT 10H X_627210 X_STRYKER ORTH,10323339,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8710.00,2613.00,3379.48,7403.5,,4267.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3658.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3379.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3701.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6532.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4355.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7403.5,,,percent of total billed charges,,,3919.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM PROX LAT LFT 10H X_627210 X_STRYKER ORTH,10323339,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8710.00,2613.00,3658.20,7403.5,,4267.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3658.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4393.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3701.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6532.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4355.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6532.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7403.5,,,percent of total billed charges,,,4006.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT TENDON REGENETEN MED,10323340,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT TENDON REGENETEN MED,10323340,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS TAG X_TGU313115 X_GORE MEDICAL,10323342,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,36751.00,11025.30,14259.39,31238.35,,18007.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15435.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14259.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15619.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27563.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18375.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31238.35,,,percent of total billed charges,,,16537.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS TAG X_TGU313115 X_GORE MEDICAL,10323342,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,36751.00,11025.30,15435.42,31238.35,,18007.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15435.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18537.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15619.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18375.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27563.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31238.35,,,percent of total billed charges,,,16905.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SYSTEM VACCUUM 8F,10323344,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,8818.00,2645.40,3747.65,7495.30,,5449.52,,,percent of total billed charges,,,,,,,,service not payable,4303.18,,,percent of total billed charges,,,4447.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3747.65,,,percent of total billed charges,,,,,,,,,6613.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4409.0,,,percent of total billed charges,,,,,,,,service not payable,6613.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7495.30,,,percent of total billed charges,,,4056.28,,,percent of total billed charges,,,,,,,,,5731.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5731.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CRS CEM SZ 4 LT,10323408,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CRS CEM SZ 4 LT,10323408,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATUN FEM SLV M/L 50MM FULL POR,10323409,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11512.00,3453.60,4466.66,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4466.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9785.20,,,percent of total billed charges,,,5180.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATUN FEM SLV M/L 50MM FULL POR,10323409,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11512.00,3453.60,4835.04,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5806.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9785.20,,,percent of total billed charges,,,5295.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CEMENT ATTUNE 14X30MM,10323410,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3436.00,1030.80,1333.17,2920.60,,,,,,,,,,,,,,,,,,,,1333.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1460.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2577.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1718.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2920.60,,,percent of total billed charges,,,1546.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CEMENT ATTUNE 14X30MM,10323410,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3436.00,1030.80,1460.3,2920.60,,,,,,,,,,,,,service not payable,,,,,,,1733.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1460.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2577.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1718.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2577.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2920.60,,,percent of total billed charges,,,1580.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB PRESSFIT STR 22X60MM,10323411,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB PRESSFIT STR 22X60MM,10323411,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DILATATION 30F 15CM,10323412,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1304.00,391.20,554.20,1108.40,,805.87,,,percent of total billed charges,,,,,,,,service not payable,636.35,,,percent of total billed charges,,,657.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,554.20,,,percent of total billed charges,,,,,,,,,978.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,652.0,,,percent of total billed charges,,,,,,,,service not payable,978.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1108.40,,,percent of total billed charges,,,599.84,,,percent of total billed charges,,,,,,,,,847.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,847.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 4X80MMX130CM X_US3513048 X_CR BAR,10323413,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 5X80MMX130CM X_US3513058 X_CR BAR,10323414,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 5X200MMX130CM X_US35130520 X_CR B,10323415,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 6X80MMX130CM X_US3513068 X_CR BAR,10323416,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 6X200MMX130CM X_US35130620 X_CR B,10323417,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 7X80MMX130CM X_US3513078 X_CR BAR,10323418,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON ULTSCORE 7X200MMX130CM X_US35130720 X_CR B,10323419,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ABLATION BI-D DD-CRV,10323424,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4179.88,8359.75,,6078.03,,,percent of total billed charges,,,,,,,,service not payable,4799.48,,,percent of total billed charges,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ABLATION BI-D DF-CRV,10323425,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4179.88,8359.75,,6078.03,,,percent of total billed charges,,,,,,,,service not payable,4799.48,,,percent of total billed charges,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ABLATION BI-D FF-CRV,10323426,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4179.88,8359.75,,6078.03,,,percent of total billed charges,,,,,,,,service not payable,4799.48,,,percent of total billed charges,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ABLATION BI-D FJ-CRV,10323427,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4179.88,8359.75,,6078.03,,,percent of total billed charges,,,,,,,,service not payable,4799.48,,,percent of total billed charges,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ABLATION BI-D JJ-CRV,10323428,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4179.88,8359.75,,6078.03,,,percent of total billed charges,,,,,,,,service not payable,4799.48,,,percent of total billed charges,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6392.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ADVISOR FL 15MM D-CRV,10323429,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ADVISOR FL 20MM D-CRV,10323430,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ADVISOR FL 15MM DF-CRV,10323431,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ADVISOR FL 20MM DF-CRV,10323432,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MAPPING GRID HD 8FX110CM,10323433,CDM,0272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3065.53,6131.05,,4457.63,,,percent of total billed charges,,,,,,,,service not payable,3519.94,,,percent of total billed charges,,,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,4688.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4688.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IRRIG ABLATION 6H 75MM X_PN-004 075 X_ABBOTT,10323434,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,10162.00,3048.60,4318.85,8637.70,,6280.12,,,percent of total billed charges,,,,,,,,service not payable,4959.06,,,percent of total billed charges,,,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4318.85,,,percent of total billed charges,,,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,,,,,,,service not payable,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,6605.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6605.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IRRIG ABLATION 6H 65MM X_PN-004 065 X_ABBOTT,10323435,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,10162.00,3048.60,4318.85,8637.70,,6280.12,,,percent of total billed charges,,,,,,,,service not payable,4959.06,,,percent of total billed charges,,,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4318.85,,,percent of total billed charges,,,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,,,,,,,service not payable,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,6605.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6605.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER QUADRA ALLURE MP RF,10323438,CDM,0275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,17506.00,5251.80,6792.33,14880.1,,8577.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7352.52,,,percent of total billed charges,,Paid in addition to inpatient services ,6792.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7440.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8753.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14880.1,,,percent of total billed charges,,,7877.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER QUADRA ALLURE MP RF,10323438,CDM,0275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,17506.00,5251.80,7352.52,14880.1,,8577.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7352.52,,,percent of total billed charges,,Paid in addition to outpatient services ,8830.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7440.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13129.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8753.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13129.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14880.1,,,percent of total billed charges,,,8052.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER QUADRA ALLURE MRI RF,10323439,CDM,0275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,17506.00,5251.80,6792.33,14880.1,,8577.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7352.52,,,percent of total billed charges,,Paid in addition to inpatient services ,6792.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7440.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8753.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14880.1,,,percent of total billed charges,,,7877.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER QUADRA ALLURE MRI RF,10323439,CDM,0275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,17506.00,5251.80,7352.52,14880.1,,8577.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7352.52,,,percent of total billed charges,,Paid in addition to outpatient services ,8830.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7440.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13129.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8753.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13129.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14880.1,,,percent of total billed charges,,,8052.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH UMBILICAL DUAL LUM 3.5F,10323440,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,146.00,43.80,62.05,124.10,,90.23,,,percent of total billed charges,,,,,,,,service not payable,71.25,,,percent of total billed charges,,,73.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.05,,,percent of total billed charges,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,73.0,,,percent of total billed charges,,,,,,,,service not payable,109.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,124.10,,,percent of total billed charges,,,67.16,,,percent of total billed charges,,,,,,,,,94.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS VOICE 16F 4MM X_AS1604-NS X_INHEALTH,10323441,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 16F 4MM X_AS1604-NS X_INHEALTH,10323441,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,34.58,1812.2,,,,,,,,49.53,,,fee schedule,,,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1599.0,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1599.0,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 16F 6MM,10323442,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 16F 6MM,10323442,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 16F 8MM,10323443,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 16F 8MM,10323443,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 16F 10MM,10323444,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 16F 10MM,10323444,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 16F 12MM,10323445,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 16F 12MM,10323445,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 16F 14MM X_AS1614-NS X_INHEALTH,10323446,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 16F 14MM X_AS1614-NS X_INHEALTH,10323446,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,34.58,1812.2,,,,,,,,49.53,,,fee schedule,,,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1599.0,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1599.0,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 20F 4MM X_AS2004-NS X_INHEALTH,10323447,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 20F 4MM X_AS2004-NS X_INHEALTH,10323447,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,34.58,1812.2,,,,,,,,49.53,,,fee schedule,,,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1599.0,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1599.0,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 20F 6MM X_AS2006-NS X_INHEALTH,10323448,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 20F 6MM X_AS2006-NS X_INHEALTH,10323448,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 20F 8MM X_AS2008-NS X_INHEALTH,10323449,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 20F 8MM X_AS2008-NS X_INHEALTH,10323449,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 20F 10MM X_AS2010-NS X_INHEALTH,10323450,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 20F 10MM X_AS2010-NS X_INHEALTH,10323450,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 20F 12MM X_AS2012-NS X_INHEALTH,10323451,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 20F 12MM X_AS2012-NS X_INHEALTH,10323451,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,34.58,1580.15,,,,,,,,49.53,,,fee schedule,,,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1394.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1394.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE 20F 14MM X_AS2014-NS X_INHEALTH,10323452,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE 20F 14MM X_AS2014-NS X_INHEALTH,10323452,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,34.58,1812.2,,,,,,,,49.53,,,fee schedule,,,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1599.0,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1599.0,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE DUAL 20F 6MM X_DV2006-NS X_INHEAL,10323453,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2235.00,670.50,867.18,1899.75,,,,,,,,,,,,,,,,,,,,867.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1676.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1117.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1899.75,,,percent of total billed charges,,,1005.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE DUAL 20F 6MM X_DV2006-NS X_INHEAL,10323453,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2235.00,670.50,34.58,1899.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,1127.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1676.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1117.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1676.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1899.75,,,percent of total billed charges,,,1028.10,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE DUAL 20F 8MM,10323454,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2235.00,670.50,867.18,1899.75,,,,,,,,,,,,,,,,,,,,867.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1676.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1117.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1899.75,,,percent of total billed charges,,,1005.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE DUAL 20F 8MM,10323454,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2235.00,670.50,34.58,1899.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,1127.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1676.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1117.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1676.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1899.75,,,percent of total billed charges,,,1028.10,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE DUAL 20F 10MM X_DV2010-NS X_INHEA,10323455,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2235.00,670.50,867.18,1899.75,,,,,,,,,,,,,,,,,,,,867.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1676.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1117.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1899.75,,,percent of total billed charges,,,1005.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE DUAL 20F 10MM X_DV2010-NS X_INHEA,10323455,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2235.00,670.50,34.58,1899.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,1127.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1676.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1117.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1676.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1899.75,,,percent of total billed charges,,,1028.10,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE DUAL 20F 12MM X_DV2012-NS X_INHEA,10323456,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2235.00,670.50,867.18,1899.75,,,,,,,,,,,,,,,,,,,,867.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1676.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1117.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1899.75,,,percent of total billed charges,,,1005.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE DUAL 20F 12MM X_DV2012-NS X_INHEA,10323456,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2235.00,670.50,34.58,1899.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,1127.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1676.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1117.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1676.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1899.75,,,percent of total billed charges,,,1028.10,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE DUAL 20F 14MM X_DV2014-NS X_INHEA,10323457,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,2235.00,670.50,867.18,1899.75,,,,,,,,,,,,,,,,,,,,867.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1676.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1117.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1899.75,,,percent of total billed charges,,,1005.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE DUAL 20F 14MM X_DV2014-NS X_INHEA,10323457,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,2235.00,670.50,34.58,1899.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,1127.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,949.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1676.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,1117.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1676.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1899.75,,,percent of total billed charges,,,1028.10,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 4MM X_IN1604-NS X_INHEAL,10323458,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 4MM X_IN1604-NS X_INHEAL,10323458,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 8MM X_IN1608-NS X_INHEAL,10323459,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 8MM X_IN1608-NS X_INHEAL,10323459,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 10MM X_IN-1610-NS X_INHE,10323460,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 10MM X_IN-1610-NS X_INHE,10323460,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,34.58,1231.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1086.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1086.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 12MM X_IN1612-NS X_INHEA,10323461,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 12MM X_IN1612-NS X_INHEA,10323461,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 14MM X_IN1614-NS X_INHEA,10323462,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 14MM X_IN1614-NS X_INHEA,10323462,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 16MM X_IN1616-NS X_INHEA,10323463,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 16MM X_IN1616-NS X_INHEA,10323463,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 18MM X_IN1618-NS X_INHEA,10323464,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 18MM X_IN1618-NS X_INHEA,10323464,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 16F 20MM X_IN16200-NS X_INHE,10323465,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 16F 20MM X_IN16200-NS X_INHE,10323465,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 4MM X_IN2004-NS X_INHEAL,10323466,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 4MM X_IN2004-NS X_INHEAL,10323466,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 6MM X_IN-2006-NS X_INHEA,10323467,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 6MM X_IN-2006-NS X_INHEA,10323467,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,34.58,1231.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1086.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1086.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 8MM X_IN2008-NS X_INHEAL,10323468,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 8MM X_IN2008-NS X_INHEAL,10323468,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 10MM X_IN-2010-NS X_INHE,10323469,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 10MM X_IN-2010-NS X_INHE,10323469,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,34.58,1231.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1086.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1086.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 12MM X_IN2012-NS X_INHEA,10323470,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 12MM X_IN2012-NS X_INHEA,10323470,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 14MM X_IN2014-NS X_INHEA,10323471,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 14MM X_IN2014-NS X_INHEA,10323471,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 16MM X_IN2016-NS X_INHEA,10323472,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 16MM X_IN2016-NS X_INHEA,10323472,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 18MM X_IN2018-NS X_INHEA,10323473,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 18MM X_IN2018-NS X_INHEA,10323473,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE CLSC 20F 20MM X_IN2020-NS X_INHEA,10323474,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1355.00,406.50,525.74,1151.75,,,,,,,,,,,,,,,,,,,,525.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,677.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,,609.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE CLSC 20F 20MM X_IN2020-NS X_INHEA,10323474,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,34.58,1151.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,575.88,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1016.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,677.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1016.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE RAPD 16F 6MM,10323475,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE RAPD 16F 6MM,10323475,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE RAPD 16F 8MM,10323476,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE RAPD 16F 8MM,10323476,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE RAPD 16F 10MM X_IN1610-IR X_INHEA,10323477,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE RAPD 16F 10MM X_IN1610-IR X_INHEA,10323477,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE RAPD 16F 12MM X_IN1612-IR X_INHEA,10323478,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE RAPD 16F 12MM X_IN1612-IR X_INHEA,10323478,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE RAPD 16F 14MM X_IN1614-IR X_INHEA,10323479,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE RAPD 16F 14MM X_IN1614-IR X_INHEA,10323479,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 16F 4MM X_IN1604-LEF X_INHEAL,10323480,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 16F 4MM X_IN1604-LEF X_INHEAL,10323480,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 16F 6MM X_IN1606-LEF X_INHEAL,10323481,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 16F 6MM X_IN1606-LEF X_INHEAL,10323481,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 16F 8MM X_IN1608-LEF X_INHEAL,10323482,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 16F 8MM X_IN1608-LEF X_INHEAL,10323482,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 16F 10MM X_IN1610-LEF X_INHEA,10323483,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 16F 10MM X_IN1610-LEF X_INHEA,10323483,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 16F 12MM X_IN1612-LEF X_INHEA,10323484,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 16F 12MM X_IN1612-LEF X_INHEA,10323484,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 16F 14MM X_IN1614-LEF X_INHEA,10323485,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 16F 14MM X_IN1614-LEF X_INHEA,10323485,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE TRAC 16F 4MM,10323486,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE TRAC 16F 4MM,10323486,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE TRAC 16F 6MM X_IN1606-LF X_INHEAL,10323487,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE TRAC 16F 6MM X_IN1606-LF X_INHEAL,10323487,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE TRAC 16F 8MM X_IN1608-LF X_INHEAL,10323488,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE TRAC 16F 8MM X_IN1608-LF X_INHEAL,10323488,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE TRAC 16F 10MM X_IN-1610-LF X_INHE,10323489,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1782.00,534.60,691.42,1514.7,,,,,,,,,,,,,,,,,,,,691.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1336.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,801.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE TRAC 16F 10MM X_IN-1610-LF X_INHE,10323489,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1782.00,534.60,34.58,1514.7,,,,,,,,49.53,,,fee schedule,,,,,,,,,898.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,757.35,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1336.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1336.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1514.7,,,percent of total billed charges,,,819.72,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE TRAC 16F 12MM X_IN-1612-LF X_INHE,10323490,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1782.00,534.60,691.42,1514.7,,,,,,,,,,,,,,,,,,,,691.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1336.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,801.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE TRAC 16F 12MM X_IN-1612-LF X_INHE,10323490,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1782.00,534.60,34.58,1514.7,,,,,,,,49.53,,,fee schedule,,,,,,,,,898.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,757.35,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1336.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1336.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1514.7,,,percent of total billed charges,,,819.72,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE TRAC 16F 14MM X_IN1614-LF X_INHEA,10323491,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE TRAC 16F 14MM X_IN1614-LF X_INHEA,10323491,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEIR 16F 4MM,10323492,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEIR 16F 4MM,10323492,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,34.58,1440.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1271.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1271.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEIR 16F 6MM,10323493,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEIR 16F 6MM,10323493,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,34.58,1440.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1271.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1271.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEIR 16F 8MM X_IN1608-LEIR X_INHE,10323494,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEIR 16F 8MM X_IN1608-LEIR X_INHE,10323494,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,34.58,1440.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1271.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1271.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOCIE IR 20F 6MM X_IN2006-IR X_INHEALTH,10323495,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOCIE IR 20F 6MM X_IN2006-IR X_INHEALTH,10323495,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOCIE IR 20F 8MM X_IN2008-IR X_INHEALTH,10323496,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOCIE IR 20F 8MM X_IN2008-IR X_INHEALTH,10323496,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOCIE IR 20F 10MM X_IN2010-IR X_INHEALT,10323497,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOCIE IR 20F 10MM X_IN2010-IR X_INHEALT,10323497,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOCIE IR 20F 12MM X_IN2012-IR X_INHEALT,10323498,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOCIE IR 20F 12MM X_IN2012-IR X_INHEALT,10323498,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,34.58,1348.10,,,,,,,,49.53,,,fee schedule,,,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1189.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1189.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 20F 4MM X_IN2004-LEF X_INHEAL,10323499,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 20F 4MM X_IN2004-LEF X_INHEAL,10323499,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 20F 6MM X_IN2006-LEF X_INHEAL,10323500,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 20F 6MM X_IN2006-LEF X_INHEAL,10323500,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 20F 8MM,10323501,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 20F 8MM,10323501,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 20F 10MM X_IN2010-LEF X_INHEA,10323502,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 20F 10MM X_IN2010-LEF X_INHEA,10323502,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 20F 12MM X_IN2012-LEF X_INHEA,10323503,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 20F 12MM X_IN2012-LEF X_INHEA,10323503,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEF 20F 14MM X_IN2014-LEF X_INHEA,10323504,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1573.00,471.90,610.32,1337.05,,,,,,,,,,,,,,,,,,,,610.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1179.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,786.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.05,,,percent of total billed charges,,,707.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEF 20F 14MM X_IN2014-LEF X_INHEA,10323504,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1573.00,471.90,34.58,1337.05,,,,,,,,49.53,,,fee schedule,,,,,,,,,793.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,668.52,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1179.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,786.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1179.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1337.05,,,percent of total billed charges,,,723.58,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LF 20F 4MM X_IN2004-LF X_INHEALTH,10323505,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LF 20F 4MM X_IN2004-LF X_INHEALTH,10323505,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LF 20F 6MM X_IN2006-LF X_INHEALTH,10323506,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LF 20F 6MM X_IN2006-LF X_INHEALTH,10323506,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LF 20F 8MM,10323507,CDM,0274,RC,L8509,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LF 20F 8MM,10323507,CDM,0274,RC,L8509,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,90.08,1384.65,,,,,,,,129.07,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,271.52,,,fee schedule,,,90.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",131.65,,,fee schedule,,,296.44,,,fee schedule,,,,,,,,,129.07,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,267.59,,,fee schedule,,,1221.75,,,percent of total billed charges,,,129.07,,,fee schedule,,,90.08,,,fee schedule,,,131.65,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,129.07,,,fee schedule,,,1221.75,,,percent of total billed charges,,,90.08,,,fee schedule,,,131.65,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,129.07,,,fee schedule,,,,,,,,,,,,,,,129.07,,,fee schedule,,,,,,,,,130.36,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LF 20F 10MM,10323508,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LF 20F 10MM,10323508,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LF 20F 12MM X_IN2012-LF X_INHEALT,10323509,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LF 20F 12MM X_IN2012-LF X_INHEALT,10323509,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LF 20F 14MM X_IN2014-LF X_INHEALT,10323510,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1629.00,488.70,632.05,1384.65,,,,,,,,,,,,,,,,,,,,632.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.65,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LF 20F 14MM X_IN2014-LF X_INHEALT,10323510,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,34.58,1384.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,692.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1221.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,814.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1221.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEIR 20F 4MM X_IN2004-LEIR X_INHE,10323511,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEIR 20F 4MM X_IN2004-LEIR X_INHE,10323511,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,34.58,1440.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1271.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1271.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEIR 20F 6MM X_IN2006-LEIR X_INHE,10323512,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEIR 20F 6MM X_IN2006-LEIR X_INHE,10323512,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,34.58,1440.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1271.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1271.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
PROSTHESIS VOICE LEIR 20F 8MM X_IN2008-LEIR X_INHE,10323513,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VOICE LEIR 20F 8MM X_IN2008-LEIR X_INHE,10323513,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,34.58,1440.75,,,,,,,,49.53,,,fee schedule,,,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,1271.25,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,1271.25,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
CAP GEL SYS INSERTION LP 16-20,10323514,CDM,0278,RC,L8512,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP GEL SYS INSERTION LP 16-20,10323514,CDM,0278,RC,L8512,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,2.54,306.85,,,,,,,,2.54,,,fee schedule,,,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,5.34,,,fee schedule,,,,,,,,service not payable,2.59,,,fee schedule,,,5.83,,,fee schedule,,,,,,,,,2.54,,,fee schedule,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,5.26,,,fee schedule,,,270.75,,,percent of total billed charges,,,2.54,,,fee schedule,,,,,,,,service not payable,2.59,,,fee schedule,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,2.54,,,fee schedule,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,2.59,,,fee schedule,,,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,fee schedule,,,,,,,,,,,,,,,2.54,,,fee schedule,,,,,,,,,2.57,,,fee schedule,,,,,,,,
DILATOR PUNCTURE TAPERED 22F,10323519,CDM,0274,RC,L8514,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR PUNCTURE TAPERED 22F,10323519,CDM,0274,RC,L8514,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,111.48,419.05,,,,,,,,111.48,,,fee schedule,,,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,234.51,,,fee schedule,,,,,,,,service not payable,113.71,,,fee schedule,,,256.04,,,fee schedule,,,,,,,,,111.48,,,fee schedule,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,231.11,,,fee schedule,,,369.75,,,percent of total billed charges,,,111.48,,,fee schedule,,,,,,,,service not payable,113.71,,,fee schedule,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,111.48,,,fee schedule,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,113.71,,,fee schedule,,,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,111.48,,,fee schedule,,,,,,,,,,,,,,,111.48,,,fee schedule,,,,,,,,,112.59,,,fee schedule,,,,,,,,
INSERT PLUG INDWELLING 16F X_IN4069 X_INHEALTH,10323520,CDM,0274,RC,L8511,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PLUG INDWELLING 16F X_IN4069 X_INHEALTH,10323520,CDM,0274,RC,L8511,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,60.01,232.90,,,,,,,,86.0,,,fee schedule,,,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,180.92,,,fee schedule,,,60.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",87.72,,,fee schedule,,,197.52,,,fee schedule,,,,,,,,,86.0,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,178.30,,,fee schedule,,,205.5,,,percent of total billed charges,,,86.0,,,fee schedule,,,60.01,,,fee schedule,,,87.72,,,fee schedule,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,86.0,,,fee schedule,,,205.5,,,percent of total billed charges,,,60.01,,,fee schedule,,,87.72,,,fee schedule,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,86.0,,,fee schedule,,,,,,,,,,,,,,,86.0,,,fee schedule,,,,,,,,,86.86,,,fee schedule,,,,,,,,
INSERT PLUG INDWELLING 20F X_IN4070 X_INHEALTH,10323521,CDM,0274,RC,L8511,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PLUG INDWELLING 20F X_IN4070 X_INHEALTH,10323521,CDM,0274,RC,L8511,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,60.01,232.90,,,,,,,,86.0,,,fee schedule,,,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,180.92,,,fee schedule,,,60.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",87.72,,,fee schedule,,,197.52,,,fee schedule,,,,,,,,,86.0,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,178.30,,,fee schedule,,,205.5,,,percent of total billed charges,,,86.0,,,fee schedule,,,60.01,,,fee schedule,,,87.72,,,fee schedule,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,86.0,,,fee schedule,,,205.5,,,percent of total billed charges,,,60.01,,,fee schedule,,,87.72,,,fee schedule,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,86.0,,,fee schedule,,,,,,,,,,,,,,,86.0,,,fee schedule,,,,,,,,,86.86,,,fee schedule,,,,,,,,
BRUSH CLEANING BLOM SINGER X_IN4064 X_INHEALTH,10323523,CDM,0274,RC,L8513,HCPCS,,,,,,inpatient,facility,,,44.00,13.20,17.07,37.40,,,,,,,,,,,,,,,,,,,,17.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,33.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.40,,,percent of total billed charges,,,19.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRUSH CLEANING BLOM SINGER X_IN4064 X_INHEALTH,10323523,CDM,0274,RC,L8513,HCPCS,,,,,,outpatient,facility,,,44.00,13.20,6.15,37.40,,,,,,,,6.15,,,fee schedule,,,,,,,,,22.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,12.94,,,fee schedule,,,,,,,,service not payable,6.27,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,,6.15,,,fee schedule,,,,,,,,,18.70,,,percent of total billed charges,,Paid in addition to outpatient services ,12.75,,,fee schedule,,,33.0,,,percent of total billed charges,,,6.15,,,fee schedule,,,,,,,,service not payable,6.27,,,fee schedule,,,22.0,,,percent of total billed charges,,Paid in addition to outpatient services ,6.15,,,fee schedule,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,6.27,,,fee schedule,,,,,,,,,37.40,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,6.15,,,fee schedule,,,,,,,,,,,,,,,6.15,,,fee schedule,,,,,,,,,6.21,,,fee schedule,,,,,,,,
BRUSH CLEANING BLOM SINGER X_IN4065 X_INHEALTH,10323524,CDM,0274,RC,L8513,HCPCS,,,,,,inpatient,facility,,,44.00,13.20,17.07,37.40,,,,,,,,,,,,,,,,,,,,17.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,33.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.40,,,percent of total billed charges,,,19.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRUSH CLEANING BLOM SINGER X_IN4065 X_INHEALTH,10323524,CDM,0274,RC,L8513,HCPCS,,,,,,outpatient,facility,,,44.00,13.20,6.15,37.40,,,,,,,,6.15,,,fee schedule,,,,,,,,,22.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,12.94,,,fee schedule,,,,,,,,service not payable,6.27,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,,6.15,,,fee schedule,,,,,,,,,18.70,,,percent of total billed charges,,Paid in addition to outpatient services ,12.75,,,fee schedule,,,33.0,,,percent of total billed charges,,,6.15,,,fee schedule,,,,,,,,service not payable,6.27,,,fee schedule,,,22.0,,,percent of total billed charges,,Paid in addition to outpatient services ,6.15,,,fee schedule,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,6.27,,,fee schedule,,,,,,,,,37.40,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,6.15,,,fee schedule,,,,,,,,,,,,,,,6.15,,,fee schedule,,,,,,,,,6.21,,,fee schedule,,,,,,,,
BRUSH CLEANING BLOM SINGER X_IN4066 X_INHEALTH,10323525,CDM,0274,RC,L8513,HCPCS,,,,,,inpatient,facility,,,44.00,13.20,17.07,37.40,,,,,,,,,,,,,,,,,,,,17.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,33.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.40,,,percent of total billed charges,,,19.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRUSH CLEANING BLOM SINGER X_IN4066 X_INHEALTH,10323525,CDM,0274,RC,L8513,HCPCS,,,,,,outpatient,facility,,,44.00,13.20,6.15,37.40,,,,,,,,6.15,,,fee schedule,,,,,,,,,22.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,12.94,,,fee schedule,,,,,,,,service not payable,6.27,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,,6.15,,,fee schedule,,,,,,,,,18.70,,,percent of total billed charges,,Paid in addition to outpatient services ,12.75,,,fee schedule,,,33.0,,,percent of total billed charges,,,6.15,,,fee schedule,,,,,,,,service not payable,6.27,,,fee schedule,,,22.0,,,percent of total billed charges,,Paid in addition to outpatient services ,6.15,,,fee schedule,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,6.27,,,fee schedule,,,,,,,,,37.40,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,6.15,,,fee schedule,,,,,,,,,,,,,,,6.15,,,fee schedule,,,,,,,,,6.21,,,fee schedule,,,,,,,,
VALVE TRACHEAL ADJUSTABLE X_BE8025H X_INHEALTH,10323526,CDM,0274,RC,L8510,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRACHEAL ADJUSTABLE X_BE8025H X_INHEALTH,10323526,CDM,0274,RC,L8510,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,208.47,906.10,,,,,,,,298.68,,,fee schedule,,,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,628.33,,,fee schedule,,,208.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.65,,,fee schedule,,,686.0,,,fee schedule,,,,,,,,,298.68,,,fee schedule,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,619.22,,,fee schedule,,,799.5,,,percent of total billed charges,,,298.68,,,fee schedule,,,208.47,,,fee schedule,,,304.65,,,fee schedule,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,298.68,,,fee schedule,,,799.5,,,percent of total billed charges,,,208.47,,,fee schedule,,,304.65,,,fee schedule,,,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,298.68,,,fee schedule,,,,,,,,,,,,,,,298.68,,,fee schedule,,,,,,,,,301.67,,,fee schedule,,,,,,,,
DIAPHRAGM TRACHEOSTOMA VALVE X_BE8026H X_INHEALTH,10323527,CDM,0274,RC,L8510,HCPCS,,,,,,inpatient,facility,,,389.00,116.70,150.93,330.65,,,,,,,,,,,,,,,,,,,,150.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,291.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,194.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.65,,,percent of total billed charges,,,175.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAPHRAGM TRACHEOSTOMA VALVE X_BE8026H X_INHEALTH,10323527,CDM,0274,RC,L8510,HCPCS,,,,,,outpatient,facility,,,389.00,116.70,165.32,686.00,,,,,,,,298.68,,,fee schedule,,,,,,,,,196.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,628.33,,,fee schedule,,,208.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.65,,,fee schedule,,,686.00,,,fee schedule,,,,,,,,,298.68,,,fee schedule,,,,,,,,,165.32,,,percent of total billed charges,,Paid in addition to outpatient services ,619.22,,,fee schedule,,,291.75,,,percent of total billed charges,,,298.68,,,fee schedule,,,208.47,,,fee schedule,,,304.65,,,fee schedule,,,194.5,,,percent of total billed charges,,Paid in addition to outpatient services ,298.68,,,fee schedule,,,291.75,,,percent of total billed charges,,,208.47,,,fee schedule,,,304.65,,,fee schedule,,,,,,,,,330.65,,,percent of total billed charges,,,178.94,,,percent of total billed charges,,,,,,,,,,,,,,,298.68,,,fee schedule,,,,,,,,,,,,,,,298.68,,,fee schedule,,,,,,,,,301.67,,,fee schedule,,,,,,,,
FILTER TRACHEOSTOMA HUMIDIFILT X_BE1010 X_INHEALTH,10323528,CDM,0272,RC,A4481,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,152.65,,,percent of total billed charges,,,,,,,,service not payable,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FILTER CAP HUMIDIFILTER ATSV X_BE1030 X_INHEALTH,10323529,CDM,0272,RC,A4481,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FILTER REPLACEMENT FOAM HUMIDI X_BE1080 X_INHEALTH,10323531,CDM,0272,RC,A4481,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 9.5X12X36MM X_BE6298 X_INHEALTH,10323535,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 9.5X12X55MM X_BE6299 X_INHEALTH,10323536,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 10.5X13.5X36MM X_BE6300 X_INHEAL,10323537,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 9/55MM X_BE6301 X_INHEALTH,10323538,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 12X15X36MM X_BE6302 X_INHEALTH,10323539,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 12X15X55MM X_BE6303 X_INHEALTH,10323540,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 13.5X17X36MM X_BE6304 X_INHEALTH,10323541,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 13.5X17X55MM X_BE6305 X_INHEALTH,10323542,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,270.07,,,percent of total billed charges,,,,,,,,service not payable,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,218.5,,,percent of total billed charges,,,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,284.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ9 SHORT X_BMB091 X_INHEALTH,10323543,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ9 REG X_BMB092 X_INHEALTH,10323544,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ9 LONG X_BMB093 X_INHEALTH,10323545,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ10 SHORT X_BMB101 X_INHEALTH,10323546,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ10 REG X_BMB102 X_INHEALTH,10323547,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ10 LONG X_BMB103 X_INHEALTH,10323548,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ12 SHORT X_BMB121 X_INHEALTH,10323549,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ12 REG X_BMB122 X_INHEALTH,10323550,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ12 LONG X_BMB123 X_INHEALTH,10323551,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ14 SHORT X_BMB141 X_INHEALTH,10323552,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ14 REG X_BMB142 X_INHEALTH,10323553,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACHEOSTOMA SZ14 LONG X_BMB143 X_INHEALTH,10323554,CDM,0270,RC,A7524,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COVER TRACHEOSTOMA SHOWER GUARD X_BE6048 X_INHEALT,10323555,CDM,0270,RC,A7523,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,118.04,,,percent of total billed charges,,,,,,,,service not payable,93.21,,,percent of total billed charges,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,95.5,,,percent of total billed charges,,,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,124.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,124.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHOWER SHIELD SILICONE X_BE6079-R2 X_INHEALTH,10323556,CDM,0273,RC,A7523,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,149.56,,,percent of total billed charges,,,,,,,,service not payable,118.10,,,percent of total billed charges,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,121.0,,,percent of total billed charges,,,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIBERTAK KNOTLESS PRO,10323557,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIBERTAK KNOTLESS PRO,10323557,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIBERTAK DISPOSABLES STRT KIT,10323558,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,956.00,286.80,370.93,812.60,,,,,,,,,,,,,,,,,,,,370.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.60,,,percent of total billed charges,,,430.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIBERTAK DISPOSABLES STRT KIT,10323558,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,956.00,286.80,406.30,812.60,,,,,,,,,,,,,service not payable,,,,,,,482.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,717.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,812.60,,,percent of total billed charges,,,439.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG CP LPDS LFT 2MM X_626903 X_STRYKER ORTH,10324104,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7168.00,2150.40,2781.18,6092.80,,3512.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3010.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2781.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3046.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5376.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3584.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6092.80,,,percent of total billed charges,,,3225.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG CP LPDS LFT 2MM X_626903 X_STRYKER ORTH,10324104,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7168.00,2150.40,3010.56,6092.80,,3512.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3010.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3615.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3046.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5376.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3584.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5376.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6092.80,,,percent of total billed charges,,,3297.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPHERE GLENOID 36MM REV STD,10324106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8395.00,2518.50,3257.26,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3257.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7135.75,,,percent of total billed charges,,,3777.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPHERE GLENOID 36MM REV STD,10324106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8395.00,2518.50,3525.90,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4234.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7135.75,,,percent of total billed charges,,,3861.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 38MM PERFORM P,10324107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,672.00,201.60,260.74,571.20,,,,,,,,,,,,,,,,,,,,260.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.20,,,percent of total billed charges,,,302.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 38MM PERFORM P,10324107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,672.00,201.60,285.60,571.20,,,,,,,,,,,,,service not payable,,,,,,,338.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,571.20,,,percent of total billed charges,,,309.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER HUM SQUARE X_1830-0009S X_STRYKER ORTHOPAED,10324108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,821.00,246.30,318.55,697.85,,,,,,,,,,,,,,,,,,,,318.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.85,,,percent of total billed charges,,,369.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER HUM SQUARE X_1830-0009S X_STRYKER ORTHOPAED,10324108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,821.00,246.30,348.93,697.85,,,,,,,,,,,,,service not payable,,,,,,,414.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.85,,,percent of total billed charges,,,377.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUM 7X230MM X_1830-0723S X_STRYKER ORTHOPAEDI,10324109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4731.00,1419.30,1835.63,4021.35,,,,,,,,,,,,,,,,,,,,1835.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2010.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3548.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2365.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4021.35,,,percent of total billed charges,,,2128.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUM 7X230MM X_1830-0723S X_STRYKER ORTHOPAEDI,10324109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4731.00,1419.30,2010.68,4021.35,,,,,,,,,,,,,service not payable,,,,,,,2386.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2010.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3548.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2365.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3548.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4021.35,,,percent of total billed charges,,,2176.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM IMPLANT PEEK SPEEDBRIDGE X_AR-2600SBS-6 X_A,10324110,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5328.00,1598.40,2067.26,4528.80,,2610.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2237.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2067.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2264.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3996.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2664.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4528.80,,,percent of total billed charges,,,2397.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM IMPLANT PEEK SPEEDBRIDGE X_AR-2600SBS-6 X_A,10324110,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5328.00,1598.40,2237.76,4528.80,,2610.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2237.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2687.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2264.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3996.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2664.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3996.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4528.80,,,percent of total billed charges,,,2450.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 4X150X130,10324111,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY ANGEL PRP KIT US,10324112,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,1097.57,,,percent of total billed charges,,,,,,,,service not payable,866.69,,,percent of total billed charges,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,1154.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1154.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE 5.0CC ABS 2010 05,10324114,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE 5.0CC ABS 2010 05,10324114,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROXIMAL 2X32X124MM,10324117,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,24762.00,7428.60,9607.66,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9607.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21047.70,,,percent of total billed charges,,,11142.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROXIMAL 2X32X124MM,10324117,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,24762.00,7428.60,10400.04,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12489.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18571.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,21047.70,,,percent of total billed charges,,,11390.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT DISTAL 12X28X91MM,10324118,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,12523.00,3756.90,4858.92,10644.55,,6136.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5259.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4858.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5322.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9392.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6261.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10644.55,,,percent of total billed charges,,,5635.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT DISTAL 12X28X91MM,10324118,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,12523.00,3756.90,5259.66,10644.55,,6136.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5259.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6316.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5322.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9392.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6261.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9392.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10644.55,,,percent of total billed charges,,,5760.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR SYMFONY 20D,10324119,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR SYMFONY 20D,10324119,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
INCISION KIT STERISHOT DUAL,10324451,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1520.00,456.00,589.76,1292.0,,,,,,,,,,,,,,,,,,,,589.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1140.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,760.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1292.0,,,percent of total billed charges,,,684.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INCISION KIT STERISHOT DUAL,10324451,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1520.00,456.00,646.0,1292.0,,,,,,,,,,,,,service not payable,,,,,,,766.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,646.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1140.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,760.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1140.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1292.0,,,percent of total billed charges,,,699.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT SM HEX 4.0X28MM,10324453,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT SM HEX 4.0X28MM,10324453,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT SM HEX 4X40MM,10324454,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT SM HEX 4X40MM,10324454,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT SM HEX 4X34MM,10324455,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT SM HEX 4X34MM,10324455,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT SM HEX 4X32MM,10324456,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT SM HEX 4X32MM,10324456,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
XTENDO BUTTON MED ROUND X_71935602 X_SMITH NEPHEW,10324900,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1230.00,369.00,477.24,1045.5,,,,,,,,,,,,,,,,,,,,477.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
XTENDO BUTTON MED ROUND X_71935602 X_SMITH NEPHEW,10324900,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,522.75,1045.5,,,,,,,,,,,,,service not payable,,,,,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,522.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,922.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,922.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ULTRA BUTTON X_72290003 X_SMITH NEPHEW,10324901,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ULTRA BUTTON X_72290003 X_SMITH NEPHEW,10324901,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP TI STD BEND WRIST,10324903,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11209.00,3362.70,4349.09,9527.65,,5492.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4707.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4349.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4763.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8406.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5604.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9527.65,,,percent of total billed charges,,,5044.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP TI STD BEND WRIST,10324903,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11209.00,3362.70,4707.78,9527.65,,5492.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4707.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5653.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4763.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8406.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5604.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8406.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9527.65,,,percent of total billed charges,,,5156.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT T8 2.7X14MM,10324904,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT T8 2.7X14MM,10324904,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT T8 2.7X16MM,10324905,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT T8 2.7X16MM,10324905,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT T8 2.7X24MM,10324906,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT T8 2.7X24MM,10324906,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT T15 3.5 X 18,10324907,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT T15 3.5 X 18,10324907,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TI CORT SLF-TPN 3.5X20MM,10324908,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TI CORT SLF-TPN 3.5X20MM,10324908,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NLK DXTEND 4.5X30MM,10324910,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NLK DXTEND 4.5X30MM,10324910,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS ALTO HEAD 2X2.5MM X_652 X_GRACE MEDICAL,10325127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2229.00,668.70,864.85,1894.65,,,,,,,,,,,,,,,,,,,,864.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,947.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1894.65,,,percent of total billed charges,,,1003.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS ALTO HEAD 2X2.5MM X_652 X_GRACE MEDICAL,10325127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2229.00,668.70,947.32,1894.65,,,,,,,,,,,,,service not payable,,,,,,,1124.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,947.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1894.65,,,percent of total billed charges,,,1025.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PISTON ECLIPSE 0.6X6MM X_468-600 X_GRACE MEDICAL,10325128,CDM,0274,RC,L8613,HCPCS,,,,,,inpatient,facility,,,1826.00,547.80,708.49,1552.10,,,,,,,,,,,,,,,,,,,,708.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.10,,,percent of total billed charges,,,821.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PISTON ECLIPSE 0.6X6MM X_468-600 X_GRACE MEDICAL,10325128,CDM,0274,RC,L8613,HCPCS,,,,,,outpatient,facility,,,1826.00,547.80,776.05,1552.10,,,,,,,,,,,,,service not payable,,,,,,,921.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1552.10,,,percent of total billed charges,,,839.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PISTON ECLIPSE 0.6X4.75MM X_468-475 X_GRACE MEDICA,10325129,CDM,0274,RC,L8613,HCPCS,,,,,,inpatient,facility,,,1826.00,547.80,708.49,1552.10,,,,,,,,,,,,,,,,,,,,708.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.10,,,percent of total billed charges,,,821.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PISTON ECLIPSE 0.6X4.75MM X_468-475 X_GRACE MEDICA,10325129,CDM,0274,RC,L8613,HCPCS,,,,,,outpatient,facility,,,1826.00,547.80,776.05,1552.10,,,,,,,,,,,,,service not payable,,,,,,,921.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1552.10,,,percent of total billed charges,,,839.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PISTON ECLIPSE 0.5X4MM X_467-400 X_GRACE MEDICAL,10325130,CDM,0274,RC,L8613,HCPCS,,,,,,inpatient,facility,,,1826.00,547.80,708.49,1552.10,,,,,,,,,,,,,,,,,,,,708.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.10,,,percent of total billed charges,,,821.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PISTON ECLIPSE 0.5X4MM X_467-400 X_GRACE MEDICAL,10325130,CDM,0274,RC,L8613,HCPCS,,,,,,outpatient,facility,,,1826.00,547.80,776.05,1552.10,,,,,,,,,,,,,service not payable,,,,,,,921.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1552.10,,,percent of total billed charges,,,839.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PISTON ECLIPSE 0.5X5MM X_467-500 X_GRACE MEDICAL,10325131,CDM,0274,RC,L8613,HCPCS,,,,,,inpatient,facility,,,1826.00,547.80,708.49,1552.10,,,,,,,,,,,,,,,,,,,,708.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.10,,,percent of total billed charges,,,821.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PISTON ECLIPSE 0.5X5MM X_467-500 X_GRACE MEDICAL,10325131,CDM,0274,RC,L8613,HCPCS,,,,,,outpatient,facility,,,1826.00,547.80,776.05,1552.10,,,,,,,,,,,,,service not payable,,,,,,,921.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1552.10,,,percent of total billed charges,,,839.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PISTON ECLIPSE 0.5X6MM X_467-600 X_GRACE MEDICAL,10325132,CDM,0278,RC,L8613,HCPCS,,,,,,inpatient,facility,,,1826.00,547.80,708.49,1552.10,,,,,,,,,,,,,,,,,,,,708.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.10,,,percent of total billed charges,,,821.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PISTON ECLIPSE 0.5X6MM X_467-600 X_GRACE MEDICAL,10325132,CDM,0278,RC,L8613,HCPCS,,,,,,outpatient,facility,,,1826.00,547.80,776.05,1552.10,,,,,,,,,,,,,service not payable,,,,,,,921.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,913.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1369.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1552.10,,,percent of total billed charges,,,839.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTERED ALTO TOTAL 2.5X7MM,10325133,CDM,0278,RC,L8613,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTERED ALTO TOTAL 2.5X7MM,10325133,CDM,0278,RC,L8613,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALTO CENTERED TOTAL 1.5X5.6MM X_655 X_GRACE MEDICA,10325134,CDM,0278,RC,L8613,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTO CENTERED TOTAL 1.5X5.6MM X_655 X_GRACE MEDICA,10325134,CDM,0278,RC,L8613,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PASSER SCORPION SL MF 16X6MM X_AR-13999MF X_ARTHRE,10325136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,13097.00,3929.10,5081.64,11132.45,,6417.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5500.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5081.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5566.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9822.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6548.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11132.45,,,percent of total billed charges,,,5893.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PASSER SCORPION SL MF 16X6MM X_AR-13999MF X_ARTHRE,10325136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,13097.00,3929.10,5500.74,11132.45,,6417.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5500.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6606.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5566.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9822.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6548.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9822.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11132.45,,,percent of total billed charges,,,6024.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE GLIDING T2XT2 14MM X_NZ122 X_AESCULAP,10325137,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE GLIDING T2XT2 14MM X_NZ122 X_AESCULAP,10325137,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM SOLYX BLUE SINGLE INCIS,10325139,CDM,0278,RC,C1771,HCPCS,,,,,,inpatient,facility,,,3449.00,1034.70,1338.21,2931.65,,,,,,,,,,,,,,,,,,,,1338.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1465.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2586.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2931.65,,,percent of total billed charges,,,1552.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM SOLYX BLUE SINGLE INCIS,10325139,CDM,0278,RC,C1771,HCPCS,,,,,,outpatient,facility,,,3449.00,1034.70,1465.82,2931.65,,,,,,,,,,,,,service not payable,,,,,,,1739.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1465.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2586.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2586.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2931.65,,,percent of total billed charges,,,1586.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CT T8 ST 2.7X40MM X_7240-2740N X_SMITH NEPHE,10325381,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CT T8 ST 2.7X40MM X_7240-2740N X_SMITH NEPHE,10325381,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK T8 ST 2.7X10MM X_7241-2710 X_SMITH NEPHE,10325382,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK T8 ST 2.7X10MM X_7241-2710 X_SMITH NEPHE,10325382,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PINS FIXATION 2.0MM 30MM X_7117-4914 X_SMITH NEPHE,10325383,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,792.00,237.60,307.30,673.20,,,,,,,,,,,,,,,,,,,,307.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,673.20,,,percent of total billed charges,,,356.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PINS FIXATION 2.0MM 30MM X_7117-4914 X_SMITH NEPHE,10325383,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,792.00,237.60,336.60,673.20,,,,,,,,,,,,,service not payable,,,,,,,399.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,336.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,673.20,,,percent of total billed charges,,,364.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL CMPNT PS 8 X_5516-F-601 X_STRYKER ORTHOPAE,10325502,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL CMPNT PS 8 X_5516-F-601 X_STRYKER ORTHOPAE,10325502,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER ALLOGRAFT CA 8X14X11MM,10325503,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER ALLOGRAFT CA 8X14X11MM,10325503,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PUTTY 10ML ATTRAX X_5015010 X_NUVASIVE,10325504,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3541.00,1062.30,1373.91,3009.85,,,,,,,,,,,,,,,,,,,,1373.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.85,,,percent of total billed charges,,,1593.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUTTY 10ML ATTRAX X_5015010 X_NUVASIVE,10325504,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3541.00,1062.30,1504.92,3009.85,,,,,,,,,,,,,service not payable,,,,,,,1786.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3009.85,,,percent of total billed charges,,,1628.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA ASYM TI 29X9MM X_5552-L-299 X_STRYKER ORTH,10325505,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA ASYM TI 29X9MM X_5552-L-299 X_STRYKER ORTH,10325505,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT ORBIT IPS X_60-000-74-09 X_KLS MARTIN L P,10325506,CDM,0278,RC,L8610,HCPCS,,,,,,inpatient,facility,,,27538.00,8261.40,10684.74,23407.30,,13493.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11565.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10684.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11703.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20653.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13769.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23407.30,,,percent of total billed charges,,,12392.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT ORBIT IPS X_60-000-74-09 X_KLS MARTIN L P,10325506,CDM,0278,RC,L8610,HCPCS,,,,,,outpatient,facility,,,27538.00,8261.40,11565.96,23407.30,,13493.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11565.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13890.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11703.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20653.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13769.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20653.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23407.30,,,percent of total billed charges,,,12667.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PASTE ALLOSYNC DBM 3ML X_ABS-2015-03 X_ARTHREX INC,10325507,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PASTE ALLOSYNC DBM 3ML X_ABS-2015-03 X_ARTHREX INC,10325507,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PACKING POD3 RUBY,10325511,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2368.95,4737.90,,3444.73,,,percent of total billed charges,,,,,,,,service not payable,2720.11,,,percent of total billed charges,,,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-MX W/TB 300MM X_133P-MX-11-T X_AL,10325514,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-MX W/TB 300MM X_133P-MX-11-T X_AL,10325514,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-MX W/TB 400MM X_133P-MX-12-T X_AL,10325515,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-MX W/TB 400MM X_133P-MX-12-T X_AL,10325515,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-MX W/TB 500MM X_133P-MX-13-T X_AL,10325516,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-MX W/TB 500MM X_133P-MX-13-T X_AL,10325516,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-MX W/TB 600MM X_133P-MX-14-T X_AL,10325517,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-MX W/TB 600MM X_133P-MX-14-T X_AL,10325517,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-MX W/TB 700MM X_133P-MX-15-T X_AL,10325518,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-MX W/TB 700MM X_133P-MX-15-T X_AL,10325518,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-MX W/TB 850MM X_133P-MX-16-T X_AL,10325519,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-MX W/TB 850MM X_133P-MX-16-T X_AL,10325519,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-SX W/TB 250MM X_133P-SX-11-T X_AL,10325520,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-SX W/TB 250MM X_133P-SX-11-T X_AL,10325520,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-SX W/TB 350MM X_133P-SX-12-T X_AL,10325521,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-SX W/TB 350MM X_133P-SX-12-T X_AL,10325521,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-SX W/TB 400MM X_133P-SX-13-T X_AL,10325522,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-SX W/TB 400MM X_133P-SX-13-T X_AL,10325522,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-SX W/TB 500MM X_133P-SX-14-T X_AL,10325523,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-SX W/TB 500MM X_133P-SX-14-T X_AL,10325523,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-SX W/TB 650MM X_133P-SX-15-T X_AL,10325524,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-SX W/TB 650MM X_133P-SX-15-T X_AL,10325524,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BR 133P-SX W/TB 800MM X_133P-SX-16-T X_AL,10325525,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5541.00,1662.30,2149.91,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.85,,,percent of total billed charges,,,2493.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BR 133P-SX W/TB 800MM X_133P-SX-16-T X_AL,10325525,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5541.00,1662.30,2327.22,4709.85,,2715.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2327.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.85,,,percent of total billed charges,,,2548.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER GUIDE 28/19MM X_MP0028/29-12 X_AGI MEDI,10325527,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,451.00,135.30,191.68,383.35,,278.72,,,percent of total billed charges,,,,,,,,service not payable,220.09,,,percent of total billed charges,,,227.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,191.68,,,percent of total billed charges,,,,,,,,,338.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,225.5,,,percent of total billed charges,,,,,,,,service not payable,338.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,383.35,,,percent of total billed charges,,,207.46,,,percent of total billed charges,,,,,,,,,293.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,293.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 6X40MMX130CM,10325528,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 6X40MMX130CM,10325528,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 6X60MMX130CM,10325529,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 6X60MMX130CM,10325529,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 6X80MMX130CM,10325530,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8508.00,2552.40,3301.10,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3301.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7231.80,,,percent of total billed charges,,,3828.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 6X80MMX130CM,10325530,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8508.00,2552.40,3573.36,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4291.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7231.80,,,percent of total billed charges,,,3913.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 6X100MMX130CM,10325531,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8508.00,2552.40,3301.10,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3301.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7231.80,,,percent of total billed charges,,,3828.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 6X100MMX130CM,10325531,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8508.00,2552.40,3573.36,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4291.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7231.80,,,percent of total billed charges,,,3913.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 6X120MMX130CM,10325532,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9491.00,2847.30,3682.51,8067.35,,4650.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3986.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3682.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4033.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7118.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4745.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8067.35,,,percent of total billed charges,,,4270.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 6X120MMX130CM,10325532,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9491.00,2847.30,3986.22,8067.35,,4650.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3986.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4787.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4033.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7118.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4745.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7118.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8067.35,,,percent of total billed charges,,,4365.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 7X40MMX130CM,10325533,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 7X40MMX130CM,10325533,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 7X60MMX130CM,10325534,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 7X60MMX130CM,10325534,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 7X80MMX130CM,10325535,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8508.00,2552.40,3301.10,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3301.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7231.80,,,percent of total billed charges,,,3828.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 7X80MMX130CM,10325535,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8508.00,2552.40,3573.36,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4291.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7231.80,,,percent of total billed charges,,,3913.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 7X100MMX130CM,10325536,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8508.00,2552.40,3301.10,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3301.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7231.80,,,percent of total billed charges,,,3828.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 7X100MMX130CM,10325536,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8508.00,2552.40,3573.36,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4291.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7231.80,,,percent of total billed charges,,,3913.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ELUVIA 7X120MMX130CM,10325537,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9491.00,2847.30,3682.51,8067.35,,4650.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3986.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3682.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4033.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7118.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4745.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8067.35,,,percent of total billed charges,,,4270.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ELUVIA 7X120MMX130CM,10325537,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9491.00,2847.30,3986.22,8067.35,,4650.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3986.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4787.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4033.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7118.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4745.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7118.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8067.35,,,percent of total billed charges,,,4365.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT AMNIOFIX 4X4CM X_APS-5440 X_MIMEDX,10325816,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT AMNIOFIX 4X4CM X_APS-5440 X_MIMEDX,10325816,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT AMNIOFIX 4X4CM X_APS-5440 X_MIMEDX,10325816,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,4590.00,1377.00,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT 4.5X68MM X_7382-6078 X_SMITH NEPHEW,10325818,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,171.00,51.30,66.35,145.35,,,,,,,,,,,,,,,,,,,,66.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,128.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.35,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT 4.5X68MM X_7382-6078 X_SMITH NEPHEW,10325818,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,171.00,51.30,72.67,145.35,,,,,,,,,,,,,service not payable,,,,,,,86.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,128.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,128.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,145.35,,,percent of total billed charges,,,78.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILATION 6F 9X4X40CM X_DR4094 X_CR BARD I,10325819,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,858.00,257.40,364.65,729.30,,530.24,,,percent of total billed charges,,,,,,,,service not payable,418.70,,,percent of total billed charges,,,432.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,364.65,,,percent of total billed charges,,,,,,,,,643.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,429.0,,,percent of total billed charges,,,,,,,,service not payable,643.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,729.30,,,percent of total billed charges,,,394.68,,,percent of total billed charges,,,,,,,,,557.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,557.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT OSFERION WEDGE 30X7.0MM X_AR-13370-1 X_ARTHR,10325821,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT OSFERION WEDGE 30X7.0MM X_AR-13370-1 X_ARTHR,10325821,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRFT OSTEOCHANDRAL CORE 10MM X_45647010 X_ALLO,10326162,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,8180.00,2454.00,3173.84,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3173.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6953.0,,,percent of total billed charges,,,3681.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRFT OSTEOCHANDRAL CORE 10MM X_45647010 X_ALLO,10326162,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,8180.00,2454.00,3435.60,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4125.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6953.0,,,percent of total billed charges,,,3762.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRFT OSTEOCHANDRAL CORE 10MM X_45647010 X_ALLO,10326162,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,8180.00,2454.00,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MED 0D MTP LT 11H 184MM,10326165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MED 0D MTP LT 11H 184MM,10326165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST FT VAR ANG 2.7X12MM,10326166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1411.00,423.30,547.47,1199.35,,,,,,,,,,,,,,,,,,,,547.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1058.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,705.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1199.35,,,percent of total billed charges,,,634.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST FT VAR ANG 2.7X12MM,10326166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1411.00,423.30,599.67,1199.35,,,,,,,,,,,,,service not payable,,,,,,,711.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,599.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1058.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,705.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1058.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1199.35,,,percent of total billed charges,,,649.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 3 TI PREBENT 4.5X50IN,10326167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 3 TI PREBENT 4.5X50IN,10326167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAVICLE LP 8H RT 11X94MM X_70-0290 X_ACUMED,10326168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4205.00,1261.50,1631.54,3574.25,,,,,,,,,,,,,,,,,,,,1631.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3574.25,,,percent of total billed charges,,,1892.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAVICLE LP 8H RT 11X94MM X_70-0290 X_ACUMED,10326168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4205.00,1261.50,1787.12,3574.25,,,,,,,,,,,,,service not payable,,,,,,,2121.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3574.25,,,percent of total billed charges,,,1934.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPEARL 75 UM 2ML,10326171,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROPEARL 75 UM 2ML,10326171,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPEARL 200 UM 2ML,10326172,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,810.82,,,percent of total billed charges,,,,,,,,service not payable,640.26,,,percent of total billed charges,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,656.0,,,percent of total billed charges,,,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPEARL 400 UM 2ML,10326173,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,810.82,,,percent of total billed charges,,,,,,,,service not payable,640.26,,,percent of total billed charges,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,656.0,,,percent of total billed charges,,,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPEARL 600 UM 2ML,10326174,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,810.82,,,percent of total billed charges,,,,,,,,service not payable,640.26,,,percent of total billed charges,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,656.0,,,percent of total billed charges,,,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPEARL 800 UM 2ML,10326175,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,810.82,,,percent of total billed charges,,,,,,,,service not payable,640.26,,,percent of total billed charges,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,656.0,,,percent of total billed charges,,,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROPEARL 1100 UM 2ML,10326176,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,810.82,,,percent of total billed charges,,,,,,,,service not payable,640.26,,,percent of total billed charges,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,656.0,,,percent of total billed charges,,,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,852.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 17.5D 6MM,10326178,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 17.5D 6MM,10326178,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 17.0D 6MM,10326179,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 17.0D 6MM,10326179,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 18.0D 6MM,10326180,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 18.0D 6MM,10326180,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 18.5D 6MM,10326181,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 18.5D 6MM,10326181,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 19.0D 6MM,10326182,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 19.0D 6MM,10326182,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 19.5D 6MM,10326183,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 19.5D 6MM,10326183,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 21.0D 6MM,10326184,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 21.0D 6MM,10326184,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 21.5D 6MM,10326185,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 21.5D 6MM,10326185,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 22.0D 6MM,10326186,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 22.0D 6MM,10326186,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 22.5D 6MM,10326187,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 22.5D 6MM,10326187,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 23.0D 6MM,10326188,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 23.0D 6MM,10326188,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS SYMFONY 23.5D 6MM,10326189,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 23.5D 6MM,10326189,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ5-6 18MM X_71453225 X_SMITH NEP,10326483,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ5-6 18MM X_71453225 X_SMITH NEP,10326483,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPR FT 5.0 LG 40MM LGT,10326484,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPR FT 5.0 LG 40MM LGT,10326484,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT PALACOS RandG X_5036964 X_HERAEUS MEDICAL,10326485,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1064.00,319.20,412.83,904.40,,,,,,,,,,,,,,,,,,,,412.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,798.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,532.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,904.40,,,percent of total billed charges,,,478.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT PALACOS RandG X_5036964 X_HERAEUS MEDICAL,10326485,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1064.00,319.20,452.20,904.40,,,,,,,,,,,,,service not payable,,,,,,,536.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,452.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,798.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,532.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,798.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,904.40,,,percent of total billed charges,,,489.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MUSTANG 6X200MM 135CM,10326486,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PART SHT THD 4X60MM X_AR-8740-60PTS X_A,10326491,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PART SHT THD 4X60MM X_AR-8740-60PTS X_A,10326491,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- DC PSV 64CM,10326492,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- DC PSV 64CM,10326492,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- SC PSV 70CM,10326493,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- SC PSV 70CM,10326493,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- DC PSV 70CM,10326494,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- DC PSV 70CM,10326494,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- SC ACTV 70CM,10326495,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- SC ACTV 70CM,10326495,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- DC ACTV 70CM,10326496,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- DC ACTV 70CM,10326496,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- SC PSV 59CM,10326497,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- SC PSV 59CM,10326497,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- SC PSV 64CM,10326498,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- SC PSV 64CM,10326498,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- DC PSV 59CM,10326499,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- DC PSV 59CM,10326499,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- SC ACTV 59CM,10326500,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- SC ACTV 59CM,10326500,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- SC ACTV 64CM,10326501,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- SC ACTV 64CM,10326501,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- DC ACTV 59CM,10326502,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- DC ACTV 59CM,10326502,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE 4 FRONT- DC ACTV 64CM,10326503,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE 4 FRONT- DC ACTV 64CM,10326503,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE DF4- SC ACTIVE 59CM,10326504,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE DF4- SC ACTIVE 59CM,10326504,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE DF4- SC ACTIVE 64CM,10326505,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE DF4- SC ACTIVE 64CM,10326505,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE DF4- SC PASSIVE 59CM,10326506,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE DF4- SC PASSIVE 59CM,10326506,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RELIANCE DF4- SC PASSIVE 64CM,10326507,CDM,0278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,12845.00,3853.50,4983.86,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4983.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10918.25,,,percent of total billed charges,,,5780.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RELIANCE DF4- SC PASSIVE 64CM,10326507,CDM,0278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,12845.00,3853.50,5394.90,10918.25,,6294.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5394.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6479.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5459.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10918.25,,,percent of total billed charges,,,5908.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT T15 3.5 X 20,10326508,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT T15 3.5 X 20,10326508,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DIAPHRAGM ARCING LF 80MM X_MXWF80 X_COOPER SURGICA,10326509,CDM,0270,RC,A4266,HCPCS,,,,,,outpatient,facility,,,286.00,85.80,121.55,243.10,,176.75,,,percent of total billed charges,,,,,,,,service not payable,139.57,,,percent of total billed charges,,,144.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,143.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,143.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,,,,,,,214.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,143.0,,,percent of total billed charges,,,,,,,,service not payable,214.5,,,percent of total billed charges,,,,,,,,service not payable,128.70,,,fee schedule,,,,,,,,,243.10,,,percent of total billed charges,,,131.56,,,percent of total billed charges,,,,,,,,,185.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,185.90,,,percent of total billed charges,,,143.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Canalith repositioning procedures per day,10326695,CDM,0450,RC,95992,CPT,,,,,,outpatient,facility,,,388.00,116.40,19.42,880.0,,239.78,,,percent of total billed charges,,,38.54,,,fee schedule,,,189.34,,,percent of total billed charges,,,195.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,81.08,,,fee schedule,,,19.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",39.23,,,fee schedule,,,88.34,,,fee schedule,,,,,,,,,38.46,,,fee schedule,,,,,,,,,,,,,,service not payable,79.91,,,fee schedule,,,291.0,,,percent of total billed charges,,,38.54,,,fee schedule,,,19.42,,,fee schedule,,,39.31,,,fee schedule,,,,,,,,service not payable,38.46,,,fee schedule,,,291.0,,,percent of total billed charges,,,89.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",39.31,,,fee schedule,,,,,,,,,329.80,,,percent of total billed charges,,,178.48,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,38.46,,,fee schedule,,,,,,,,,774.0,,,case rate,,,38.54,,,fee schedule,,,,,,,,,38.54,,,fee schedule,,,,,,,,
Canalith repositioning procedures per day,10326695,CDM,0450,RC,95992,CPT,269,EAPG,,,,outpatient,facility,,,388.00,116.40,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Weaning Parameters - Weaning Parameters Procedure/,10327033,CDM,0460,RC,94150,CPT,,,,,,outpatient,facility,,,186.00,55.80,79.05,983.0,,114.95,,,percent of total billed charges,,,,,,,,,90.77,,,percent of total billed charges,,,93.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.0,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,,85.56,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Weaning Parameters - Weaning Parameters Procedure/,10327033,CDM,0460,RC,94150,CPT,05721,APC,,,,outpatient,facility,,,186.00,55.80,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Weaning Parameters - Weaning Parameters Procedure/,10327033,CDM,0460,RC,94150,CPT,412,EAPG,,,,outpatient,facility,,,186.00,55.80,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COIL PACKING EMBOLIZATION 5CM,10327152,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,2674.70,,,percent of total billed charges,,,,,,,,service not payable,2112.06,,,percent of total billed charges,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2164.0,,,percent of total billed charges,,,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2813.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEMORAL ACET 50MM,10327153,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEMORAL ACET 50MM,10327153,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 8.0X95MM STERILE X_611095S X_STRYKER,10327154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 8.0X95MM STERILE X_611095S X_STRYKER,10327154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 8.0X105MM STERILE X_611105S X_STRYKE,10327155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 8.0X105MM STERILE X_611105S X_STRYKE,10327155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 8.0X110MM STERILE X_611110S X_STRYKE,10327156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 8.0X110MM STERILE X_611110S X_STRYKE,10327156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 8.0X120MM STERILE X_611120S X_STRYKE,10327157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 8.0X120MM STERILE X_611120S X_STRYKE,10327157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 8.0X100MM STERILE X_611100S X_STRYKE,10327158,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 8.0X100MM STERILE X_611100S X_STRYKE,10327158,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EP EZ STEER DS 7F 1X7X4X8,10327159,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,4626.00,1387.80,1966.05,3932.10,,2858.87,,,percent of total billed charges,,,,,,,,service not payable,2257.49,,,percent of total billed charges,,,2333.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1966.05,,,percent of total billed charges,,,,,,,,,3469.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2313.0,,,percent of total billed charges,,,,,,,,service not payable,3469.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3932.10,,,percent of total billed charges,,,2127.96,,,percent of total billed charges,,,,,,,,,3006.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3006.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH INDIGO 6 LARGE LUMEN,10327162,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,7393.00,2217.90,3142.03,6284.05,,4568.87,,,percent of total billed charges,,,,,,,,service not payable,3607.78,,,percent of total billed charges,,,3729.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3142.03,,,percent of total billed charges,,,,,,,,,5544.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3696.5,,,percent of total billed charges,,,,,,,,service not payable,5544.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6284.05,,,percent of total billed charges,,,3400.78,,,percent of total billed charges,,,,,,,,,4805.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4805.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL < 4.8CM X_14817048 X_ALLOSOURCE,10327306,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6639.00,1991.70,2575.93,5643.15,,3253.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2788.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2575.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2821.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5643.15,,,percent of total billed charges,,,2987.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL < 4.8CM X_14817048 X_ALLOSOURCE,10327306,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6639.00,1991.70,2788.38,5643.15,,3253.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2788.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3348.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2821.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4979.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5643.15,,,percent of total billed charges,,,3053.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON INTRAGASTRIC ORBERA,10327307,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6066.00,1819.80,2353.61,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2353.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5156.10,,,percent of total billed charges,,,2729.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON INTRAGASTRIC ORBERA,10327307,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2547.72,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS NP LGN SZ3 LT,10327308,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS NP LGN SZ3 LT,10327308,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ADV PRO CROABLATION,10327309,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,15408.00,4622.40,6548.40,13096.80,,9522.14,,,percent of total billed charges,,,,,,,,service not payable,7519.10,,,percent of total billed charges,,,7771.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6548.40,,,percent of total billed charges,,,,,,,,,11556.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7704.0,,,percent of total billed charges,,,,,,,,service not payable,11556.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13096.80,,,percent of total billed charges,,,7087.68,,,percent of total billed charges,,,,,,,,,10015.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,10015.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENSEAL X1 CURVED JAW 37CM,10327310,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2675.00,802.50,1037.90,2273.75,,,,,,,,,,,,,,,,,,,,1037.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1136.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2006.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1337.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2273.75,,,percent of total billed charges,,,1203.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENSEAL X1 CURVED JAW 37CM,10327310,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2675.00,802.50,1136.88,2273.75,,,,,,,,,,,,,service not payable,,,,,,,1349.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1136.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2006.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1337.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2006.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2273.75,,,percent of total billed charges,,,1230.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 18.5 D 6MM,10327311,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 18.5 D 6MM,10327311,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA3 5.5X50MM X_482615555 X_STRYKER SPI,10327313,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA3 5.5X50MM X_482615555 X_STRYKER SPI,10327313,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY INST REV FLEX TH 0 1.5MM,10327314,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6841.00,2052.30,2654.31,5814.85,,3352.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2873.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2654.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2907.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5814.85,,,percent of total billed charges,,,3078.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY INST REV FLEX TH 0 1.5MM,10327314,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6841.00,2052.30,2873.22,5814.85,,3352.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2873.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3450.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2907.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5814.85,,,percent of total billed charges,,,3146.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM FLEX SZ1B 66MM,10327315,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14965.00,4489.50,5806.42,12720.25,,7332.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6285.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5806.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6360.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11223.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7482.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12720.25,,,percent of total billed charges,,,6734.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM FLEX SZ1B 66MM,10327315,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14965.00,4489.50,6285.30,12720.25,,7332.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6285.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7548.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6360.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11223.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7482.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11223.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12720.25,,,percent of total billed charges,,,6883.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE PERF REV LAT 3X25MM,10327316,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11145.00,3343.50,4324.26,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9473.25,,,percent of total billed charges,,,5015.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE PERF REV LAT 3X25MM,10327316,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11145.00,3343.50,4680.90,9473.25,,5461.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4680.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5621.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4736.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8358.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5572.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8358.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9473.25,,,percent of total billed charges,,,5126.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL COMPONENT LEGION SZ3 LT X_71933648 X_SMITH,10327317,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL COMPONENT LEGION SZ3 LT X_71933648 X_SMITH,10327317,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RAO-Transperineal placemnt needle/cath prostate fo,10327415,CDM,0360,RC,55875,CPT,,,,,,outpatient,facility,,,12612.00,3783.60,4917.20,10720.20,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,6361.49,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7120.0,,,case rate,,,,,,,,,9459.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8377.0,,,case rate,,,,,,,,,9459.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10720.20,,,percent of total billed charges,,,5801.52,,,percent of total billed charges,,,,,,,,,7221.0,,,case rate,,,,,,,,,,,,,,,6354.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
RAO-Transperineal placemnt needle/cath prostate fo,10327415,CDM,0360,RC,55875,CPT,05375,APC,,,,outpatient,facility,,,12612.00,3783.60,4676.05,11196.70,,,,,,,,4875.02,,,fee schedule,,,,,,,,,,,,,,,10255.38,,,fee schedule,,,4676.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4972.52,,,fee schedule,,,11196.70,,,fee schedule,,,,,,,,,4875.02,,,fee schedule,,,,,,,,,,,,,,,10106.75,,,fee schedule,,,,,,,,,4875.02,,,fee schedule,,,4676.05,,,fee schedule,,,4972.52,,,fee schedule,,,,,,,,,4875.02,,,fee schedule,,,,,,,,,4676.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",4972.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4875.02,,,fee schedule,,,,,,,,,,,,,,,4875.02,,,fee schedule,,,,,,,,,4923.57,,,fee schedule,,,,,,,,
RAO-Transperineal placemnt needle/cath prostate fo,10327415,CDM,0360,RC,55875,CPT,184,EAPG,,,,outpatient,facility,,,12612.00,3783.60,6402.36,12718.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12718.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,10810.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6402.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6402.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6402.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7490.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,8239.24,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PROTECTANT CAVILON 2.7ML X_4513-5050 X_356359,10327490,CDM,0272,RC,A6250,HCPCS,,,,,,outpatient,facility,,,62.00,18.60,26.35,52.70,,38.32,,,percent of total billed charges,,,,,,,,service not payable,30.26,,,percent of total billed charges,,,31.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,26.35,,,percent of total billed charges,,,,,,,,,46.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,31.0,,,percent of total billed charges,,,,,,,,service not payable,46.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,52.70,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,,,,,,,40.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,40.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WALKER CAM BOOT TD AIR STD XL X_24-139 X_342122,10327491,CDM,0274,RC,L4386,HCPCS,,,,,,inpatient,facility,,,176.00,52.80,68.29,149.60,,,,,,,,,,,,,,,,,,,,68.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,132.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.60,,,percent of total billed charges,,,79.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM BOOT TD AIR STD XL X_24-139 X_342122,10327491,CDM,0274,RC,L4386,HCPCS,,,,,,outpatient,facility,,,176.00,52.80,74.80,397.76,,,,,,,,173.18,,,fee schedule,,,,,,,,,88.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,364.32,,,fee schedule,,,130.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",176.64,,,fee schedule,,,397.76,,,fee schedule,,,,,,,,,173.18,,,fee schedule,,,,,,,,,74.80,,,percent of total billed charges,,Paid in addition to outpatient services ,359.04,,,fee schedule,,,132.0,,,percent of total billed charges,,,173.18,,,fee schedule,,,130.59,,,fee schedule,,,176.64,,,fee schedule,,,88.0,,,percent of total billed charges,,Paid in addition to outpatient services ,173.18,,,fee schedule,,,132.0,,,percent of total billed charges,,,130.59,,,fee schedule,,,176.64,,,fee schedule,,,,,,,,,149.60,,,percent of total billed charges,,,80.96,,,percent of total billed charges,,,,,,,,,,,,,,,173.18,,,fee schedule,,,,,,,,,,,,,,,173.18,,,fee schedule,,,,,,,,,173.18,,,fee schedule,,,,,,,,
WALKER CAM BOOT TD AIR STD XL X_24-139 X_342122 -A,10327492,CDM,0274,RC,L4386,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM BOOT TD AIR STD XL X_24-139 X_342122 -A,10327492,CDM,0274,RC,L4386,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,384.20,,,,,,,,167.28,,,fee schedule,,,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,351.90,,,fee schedule,,,130.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",170.63,,,fee schedule,,,384.20,,,fee schedule,,,,,,,,,167.28,,,fee schedule,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,346.80,,,fee schedule,,,127.5,,,percent of total billed charges,,,167.28,,,fee schedule,,,130.59,,,fee schedule,,,170.63,,,fee schedule,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,167.28,,,fee schedule,,,127.5,,,percent of total billed charges,,,130.59,,,fee schedule,,,170.63,,,fee schedule,,,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,167.28,,,fee schedule,,,,,,,,,,,,,,,167.28,,,fee schedule,,,,,,,,,167.28,,,fee schedule,,,,,,,,
SHEATH DRYSEAL FLEX 14F 33CM,10327520,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.13,2044.25,,1486.29,,,percent of total billed charges,,,,,,,,service not payable,1173.64,,,percent of total billed charges,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.13,,,percent of total billed charges,,,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 6D 12X23X11MM X_48951126 X_STRYKER,10327523,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 6D 12X23X11MM X_48951126 X_STRYKER,10327523,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 BEIGE 14 X_2001AD14 X_JULIUS Z,10327529,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,30.36,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 BLACK SZ 2,10327530,CDM,0271,RC,A6530,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,30.36,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 5MMX15CM 0.018IN 120CM,10327531,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13408.00,4022.40,5202.30,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5202.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11396.80,,,percent of total billed charges,,,6033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 5MMX15CM 0.018IN 120CM,10327531,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13408.00,4022.40,5631.36,11396.80,,6569.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6763.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5698.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10056.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6704.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10056.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11396.80,,,percent of total billed charges,,,6167.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6MMX10CM 0.035IN 120CM,10327532,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11703.00,3510.90,4540.76,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4540.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9947.55,,,percent of total billed charges,,,5266.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6MMX10CM 0.035IN 120CM,10327532,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11703.00,3510.90,4915.26,9947.55,,5734.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4915.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5902.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4973.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8777.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8777.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9947.55,,,percent of total billed charges,,,5383.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 BROWN SZ2 X_2001ADFF53 X_JULIU,10327533,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,30.36,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ISTENT TRAEBCULAR MICRO BYPASS,10327534,CDM,0278,RC,C1783,HCPCS,,,,,,inpatient,facility,,,6310.00,1893.00,2448.28,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2448.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5363.5,,,percent of total billed charges,,,2839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISTENT TRAEBCULAR MICRO BYPASS,10327534,CDM,0278,RC,C1783,HCPCS,,,,,,outpatient,facility,,,6310.00,1893.00,2650.20,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3182.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5363.5,,,percent of total billed charges,,,2902.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING WOUND MEPILEX 4X8IN,10327535,CDM,0272,RC,A6212,HCPCS,,,,,,outpatient,facility,,,152.00,45.60,64.60,129.20,,93.94,,,percent of total billed charges,,,,,,,,service not payable,74.18,,,percent of total billed charges,,,76.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,64.60,,,percent of total billed charges,,,,,,,,,114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,76.0,,,percent of total billed charges,,,,,,,,service not payable,114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,129.20,,,percent of total billed charges,,,69.92,,,percent of total billed charges,,,,,,,,,98.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,98.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING WOUND MEPILEX 4X10IN,10327536,CDM,0272,RC,A6212,HCPCS,,,,,,outpatient,facility,,,136.00,40.80,57.80,115.60,,84.05,,,percent of total billed charges,,,,,,,,service not payable,66.37,,,percent of total billed charges,,,68.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,57.80,,,percent of total billed charges,,,,,,,,,102.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,68.0,,,percent of total billed charges,,,,,,,,service not payable,102.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,115.60,,,percent of total billed charges,,,62.56,,,percent of total billed charges,,,,,,,,,88.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,88.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING WOUND MEPILEX 4X12IN,10327537,CDM,0272,RC,A6212,HCPCS,,,,,,outpatient,facility,,,155.00,46.50,65.88,131.75,,95.79,,,percent of total billed charges,,,,,,,,service not payable,75.64,,,percent of total billed charges,,,78.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.88,,,percent of total billed charges,,,,,,,,,116.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.5,,,percent of total billed charges,,,,,,,,service not payable,116.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,131.75,,,percent of total billed charges,,,71.30,,,percent of total billed charges,,,,,,,,,100.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,100.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLING SYSTEM BLUE ADVANTAGE,10327538,CDM,0278,RC,C1771,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLING SYSTEM BLUE ADVANTAGE,10327538,CDM,0278,RC,C1771,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY CATHETER FOLEY 18F,10327540,CDM,0272,RC,A4312,HCPCS,,,,,,outpatient,facility,,,143.00,42.90,60.77,121.55,,88.37,,,percent of total billed charges,,,,,,,,service not payable,69.78,,,percent of total billed charges,,,72.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,71.5,,,percent of total billed charges,,,,,,,,service not payable,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT URINARY INCONT 4X7CM,10327541,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4367.00,1310.10,1694.40,3711.95,,,,,,,,,,,,,,,,,,,,1694.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1855.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3275.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2183.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3711.95,,,percent of total billed charges,,,1965.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT URINARY INCONT 4X7CM,10327541,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4367.00,1310.10,1855.97,3711.95,,,,,,,,,,,,,service not payable,,,,,,,2202.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1855.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3275.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2183.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3275.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3711.95,,,percent of total billed charges,,,2008.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT F-D 5MM SZ7 RT,10327542,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3544.00,1063.20,1375.07,3012.40,,,,,,,,,,,,,,,,,,,,1375.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3012.40,,,percent of total billed charges,,,1594.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT F-D 5MM SZ7 RT,10327542,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3544.00,1063.20,1506.2,3012.40,,,,,,,,,,,,,service not payable,,,,,,,1787.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3012.40,,,percent of total billed charges,,,1630.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT F-D 10MM SZ7 RT,10327543,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT F-D 10MM SZ7 RT,10327543,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXTENDER 25MM X_5571-S-025 X_STRYKER ORTHOPAE,10327544,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3419.00,1025.70,1326.57,2906.15,,,,,,,,,,,,,,,,,,,,1326.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1453.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2564.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1709.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2906.15,,,percent of total billed charges,,,1538.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXTENDER 25MM X_5571-S-025 X_STRYKER ORTHOPAE,10327544,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3419.00,1025.70,1453.08,2906.15,,,,,,,,,,,,,service not payable,,,,,,,1724.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1453.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2564.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1709.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2564.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2906.15,,,percent of total billed charges,,,1572.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM PICO WOUND VAC X_NPWT 15X30CM X_66800956 X_,10327545,CDM,0272,RC,A6550,HCPCS,,,,,,outpatient,facility,,,1203.00,360.90,511.27,1022.55,,743.45,,,percent of total billed charges,,,,,,,,service not payable,587.06,,,percent of total billed charges,,,606.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,511.27,,,percent of total billed charges,,,,,,,,,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,601.5,,,percent of total billed charges,,,,,,,,service not payable,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1022.55,,,percent of total billed charges,,,553.38,,,percent of total billed charges,,,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7MMX15MM X_7240-2715 X_SMITH N,10327547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7MMX15MM X_7240-2715 X_SMITH N,10327547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7MMX24MM X_7240-2724 X_SMITH N,10327548,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7MMX24MM X_7240-2724 X_SMITH N,10327548,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7MMX28MM X_7240-2728 X_SMITH N,10327549,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7MMX28MM X_7240-2728 X_SMITH N,10327549,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7MM X34MM X_7240-2734 X_SMITH,10327550,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7MM X34MM X_7240-2734 X_SMITH,10327550,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y-TINE EVOS 5H X_7244-2784 X_SMITH NEPHEW,10327551,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4072.00,1221.60,1579.94,3461.20,,,,,,,,,,,,,,,,,,,,1579.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1730.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3054.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2036.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3461.20,,,percent of total billed charges,,,1832.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y-TINE EVOS 5H X_7244-2784 X_SMITH NEPHEW,10327551,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4072.00,1221.60,1730.60,3461.20,,,,,,,,,,,,,service not payable,,,,,,,2053.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1730.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3054.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2036.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3054.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3461.20,,,percent of total billed charges,,,1873.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7MMX32MM X_7240-2732 X_SMITH N,10327552,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7MMX32MM X_7240-2732 X_SMITH N,10327552,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7MMX36MM X_7240-2736 X_SMITH N,10327553,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7MMX36MM X_7240-2736 X_SMITH N,10327553,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT 2.7X13MM,10327554,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT 2.7X13MM,10327554,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE MP1 7F 100CM,10327555,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE MP1 7F 90CM,10327556,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE MP1 8F 100CM,10327557,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE MP1 8F 90CM X_LA8MP1D X_MEDTRONIC USA I,10327558,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TURNPIKE HARD TIP 135CM,10327559,CDM,0272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,2382.00,714.60,1012.35,2024.7,,1472.08,,,percent of total billed charges,,,,,,,,service not payable,1162.42,,,percent of total billed charges,,,1201.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1012.35,,,percent of total billed charges,,,,,,,,,1786.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1191.0,,,percent of total billed charges,,,,,,,,service not payable,1786.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2024.7,,,percent of total billed charges,,,1095.72,,,percent of total billed charges,,,,,,,,,1548.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1548.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE ASAHI FIELDER XT-R 300CM X_APW14R305S X_,10327560,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUOH 03 300CM PRE SHAPE,10327561,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE PTFE 0.013IN 350CM X_7390 X_TELEFLEX MED,10327562,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,923.00,276.90,392.27,784.55,,570.41,,,percent of total billed charges,,,,,,,,service not payable,450.42,,,percent of total billed charges,,,465.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,392.27,,,percent of total billed charges,,,,,,,,,692.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,461.5,,,percent of total billed charges,,,,,,,,service not payable,692.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,784.55,,,percent of total billed charges,,,424.58,,,percent of total billed charges,,,,,,,,,599.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,599.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 SHT SZ2 X_2001ADSH10 X_JULIUS,10327563,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,30.36,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 5X40X75,10327565,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRFT CONT LEG 14.5MM10CM,10327566,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15303.00,4590.90,5937.56,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5937.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13007.55,,,percent of total billed charges,,,6886.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRFT CONT LEG 14.5MM10CM,10327566,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15303.00,4590.90,6427.26,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7718.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13007.55,,,percent of total billed charges,,,7039.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Vaginal - OB Method of Delivery,10327809,CDM,0720,RC,59409,CPT,,,,,,outpatient,facility,,,3763.00,1128.90,57.0,3198.55,,2325.53,,,percent of total billed charges,,,,,,,,,1836.34,,,percent of total billed charges,,,1898.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1599.28,,,percent of total billed charges,,,,,,,,,2822.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1881.5,,,percent of total billed charges,,,,,,,,,2822.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3198.55,,,percent of total billed charges,,,1730.98,,,percent of total billed charges,,,,,,,,,65.0,,FormulaCPE:  {Units in Service Type} * 65.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 65.00 End FormulaCPE,,,,,,,,,,,,,57.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Vaginal - OB Method of Delivery,10327809,CDM,0720,RC,59409,CPT,05414,APC,,,,outpatient,facility,,,3763.00,1128.90,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Vaginal - OB Method of Delivery,10327809,CDM,0720,RC,59409,CPT,195,EAPG,,,,outpatient,facility,,,3763.00,1128.90,3133.32,5262.10,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5262.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4472.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4537.78,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4991.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Vaginal forcep assist - OB Method of Delivery,10327811,CDM,0720,RC,59409,CPT,,,,,,outpatient,facility,,,3763.00,1128.90,57.0,3198.55,,2325.53,,,percent of total billed charges,,,,,,,,,1836.34,,,percent of total billed charges,,,1898.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1599.28,,,percent of total billed charges,,,,,,,,,2822.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1881.5,,,percent of total billed charges,,,,,,,,,2822.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3198.55,,,percent of total billed charges,,,1730.98,,,percent of total billed charges,,,,,,,,,65.0,,FormulaCPE:  {Units in Service Type} * 65.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 65.00 End FormulaCPE,,,,,,,,,,,,,57.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Vaginal forcep assist - OB Method of Delivery,10327811,CDM,0720,RC,59409,CPT,05414,APC,,,,outpatient,facility,,,3763.00,1128.90,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Vaginal forcep assist - OB Method of Delivery,10327811,CDM,0720,RC,59409,CPT,195,EAPG,,,,outpatient,facility,,,3763.00,1128.90,3133.32,5262.10,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5262.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4472.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4537.78,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4991.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Vaginal forcep and vacuum - OB Method of Delivery,10327812,CDM,0720,RC,59409,CPT,,,,,,outpatient,facility,,,3982.00,1194.60,57.0,3384.70,,2460.88,,,percent of total billed charges,,,,,,,,,1943.22,,,percent of total billed charges,,,2008.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1692.35,,,percent of total billed charges,,,,,,,,,2986.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1991.0,,,percent of total billed charges,,,,,,,,,2986.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3384.70,,,percent of total billed charges,,,1831.72,,,percent of total billed charges,,,,,,,,,65.0,,FormulaCPE:  {Units in Service Type} * 65.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 65.00 End FormulaCPE,,,,,,,,,,,,,57.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Vaginal forcep and vacuum - OB Method of Delivery,10327812,CDM,0720,RC,59409,CPT,05414,APC,,,,outpatient,facility,,,3982.00,1194.60,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Vaginal forcep and vacuum - OB Method of Delivery,10327812,CDM,0720,RC,59409,CPT,195,EAPG,,,,outpatient,facility,,,3982.00,1194.60,3133.32,5262.10,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5262.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4472.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3133.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4537.78,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4991.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MESH PHASIX 35X35CM X_1193535 X_BARD,10328190,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,38465.00,11539.50,14924.42,32695.25,,18847.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16155.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14924.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16347.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28848.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32695.25,,,percent of total billed charges,,,17309.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH PHASIX 35X35CM X_1193535 X_BARD,10328190,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,38465.00,11539.50,16155.30,32695.25,,18847.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16155.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19401.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16347.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28848.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28848.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32695.25,,,percent of total billed charges,,,17693.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 16D 40MM,10328197,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 16D 40MM,10328197,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 16D 60MM,10328198,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 16D 60MM,10328198,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 16D 80MM,10328199,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 16D 80MM,10328199,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 18D 40MM,10328200,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 18D 40MM,10328200,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 18D 60MM,10328201,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 18D 60MM,10328201,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 18D 80MM,10328202,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 18D 80MM,10328202,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 20D 40MM,10328203,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 20D 40MM,10328203,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 20D 60MM,10328204,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 20D 60MM,10328204,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 20D 80MM,10328205,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 20D 80MM,10328205,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BREAST SALINE HP 465ML X_68HP-465 X_ALLERG,10328534,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BREAST SALINE HP 465ML X_68HP-465 X_ALLERG,10328534,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT WALL 22X45MM 100CM,10328536,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4271.00,1281.30,1657.15,3630.35,,,,,,,,,,,,,,,,,,,,1657.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1815.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3203.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2135.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3630.35,,,percent of total billed charges,,,1921.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT WALL 22X45MM 100CM,10328536,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4271.00,1281.30,1815.18,3630.35,,,,,,,,,,,,,service not payable,,,,,,,2154.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1815.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3203.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2135.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3203.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3630.35,,,percent of total billed charges,,,1964.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT WALL 22X70MM 11F 100CM,10328537,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,6519.00,1955.70,2529.37,5541.15,,3194.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2737.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2529.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2770.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4889.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3259.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5541.15,,,percent of total billed charges,,,2933.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT WALL 22X70MM 11F 100CM,10328537,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,6519.00,1955.70,2737.98,5541.15,,3194.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2737.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3288.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2770.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4889.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3259.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4889.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5541.15,,,percent of total billed charges,,,2998.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT WALL 11X45MM 100CM,10328538,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4271.00,1281.30,1657.15,3630.35,,,,,,,,,,,,,,,,,,,,1657.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1815.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3203.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2135.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3630.35,,,percent of total billed charges,,,1921.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT WALL 11X45MM 100CM,10328538,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4271.00,1281.30,1815.18,3630.35,,,,,,,,,,,,,service not payable,,,,,,,2154.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1815.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3203.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2135.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3203.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3630.35,,,percent of total billed charges,,,1964.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IMPELLA CP ABIO 9-14F,10328543,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,54637.00,16391.10,21199.16,46441.45,,26772.13,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22947.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,21199.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23220.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,40977.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27318.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46441.45,,,percent of total billed charges,,,24586.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH IMPELLA CP ABIO 9-14F,10328543,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,54637.00,16391.10,22947.54,46441.45,,26772.13,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22947.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,27558.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,23220.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,40977.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27318.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,40977.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,46441.45,,,percent of total billed charges,,,25133.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR 52MM,10328684,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR 52MM,10328684,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR 60MM,10328686,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR 60MM,10328686,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ACETABULAR 36X60MM,10328687,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ACETABULAR 36X60MM,10328687,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG 8H X_427008S X_STRYKER,10328688,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,747.00,224.10,289.84,634.95,,,,,,,,,,,,,,,,,,,,289.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,373.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,634.95,,,percent of total billed charges,,,336.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG 8H X_427008S X_STRYKER,10328688,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,747.00,224.10,317.47,634.95,,,,,,,,,,,,,service not payable,,,,,,,376.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,317.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,560.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,373.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,560.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,634.95,,,percent of total billed charges,,,343.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ8 LT X_71423228 X_SMITH NEPHEW,10328689,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ8 LT X_71423228 X_SMITH NEPHEW,10328689,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SEEKER 0.035X135,10328690,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,540.75,,,percent of total billed charges,,,,,,,,service not payable,427.0,,,percent of total billed charges,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT FLIXENE 8X50MM X_25060 X_ATRIUM MEDICAL,10328691,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FLIXENE 8X50MM X_25060 X_ATRIUM MEDICAL,10328691,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE EXPANDABLE 10X28MM 6DEG 9-13MM X_541-0008 X_S,10328692,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE EXPANDABLE 10X28MM 6DEG 9-13MM X_541-0008 X_S,10328692,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH PLUERX X_50-7280 X_CAREFUSION,10328693,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,127.00,38.10,53.98,107.95,,78.49,,,percent of total billed charges,,,,,,,,service not payable,61.98,,,percent of total billed charges,,,64.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,53.98,,,percent of total billed charges,,,,,,,,,95.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,63.5,,,percent of total billed charges,,,,,,,,service not payable,95.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,107.95,,,percent of total billed charges,,,58.42,,,percent of total billed charges,,,,,,,,,82.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,82.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE HEART AORTIC SM 21MM X_ICV1208 X_LIVANOVA,10328696,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26210.00,7863.00,10169.48,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10169.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22278.5,,,percent of total billed charges,,,11794.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE HEART AORTIC SM 21MM X_ICV1208 X_LIVANOVA,10328696,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26210.00,7863.00,11008.20,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13220.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22278.5,,,percent of total billed charges,,,12056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE HEART AORTIC SM 23MM X_ICV1209 X_LIVANOVA,10328697,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26210.00,7863.00,10169.48,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10169.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22278.5,,,percent of total billed charges,,,11794.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE HEART AORTIC SM 23MM X_ICV1209 X_LIVANOVA,10328697,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26210.00,7863.00,11008.20,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13220.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22278.5,,,percent of total billed charges,,,12056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE HEART AORTIC LG 25MM X_ICV1210 X_LIVANOVA,10328698,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26210.00,7863.00,10169.48,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10169.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22278.5,,,percent of total billed charges,,,11794.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE HEART AORTIC LG 25MM X_ICV1210 X_LIVANOVA,10328698,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26210.00,7863.00,11008.20,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13220.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22278.5,,,percent of total billed charges,,,12056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE HEART AORTIC XL 27MM X_ICV1211 X_LIVANOVA,10328699,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26210.00,7863.00,10169.48,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10169.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22278.5,,,percent of total billed charges,,,11794.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE HEART AORTIC XL 27MM X_ICV1211 X_LIVANOVA,10328699,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26210.00,7863.00,11008.20,22278.5,,12842.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11008.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13220.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11139.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13105.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19657.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22278.5,,,percent of total billed charges,,,12056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 24MM X_4DM-24 X_LIVANOV,10328700,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 24MM X_4DM-24 X_LIVANOV,10328700,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 26MM X_4DM-26 X_LIVANOV,10328701,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 26MM X_4DM-26 X_LIVANOV,10328701,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 28MM X_4DM-28 X_LIVANOV,10328702,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 28MM X_4DM-28 X_LIVANOV,10328702,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 30MM X_4DM-30 X_LIVANOV,10328703,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 30MM X_4DM-30 X_LIVANOV,10328703,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 32MM X_4DM-32 X_LIVANOV,10328704,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 32MM X_4DM-32 X_LIVANOV,10328704,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 34MM X_4DM-34 X_LIVANOV,10328705,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 34MM X_4DM-34 X_LIVANOV,10328705,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 36MM X_4DM-36 X_LIVANOV,10328706,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 36MM X_4DM-36 X_LIVANOV,10328706,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 38MM X_4DM-38 X_LIVANOV,10328707,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 38MM X_4DM-38 X_LIVANOV,10328707,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RING 40MM X_4DM-40 X_LIVANOV,10328708,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RING 40MM X_4DM-40 X_LIVANOV,10328708,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MEMO 4D MITRAL REPAIR RNG 42MM,10328709,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMO 4D MITRAL REPAIR RNG 42MM,10328709,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER SUPER FIRM TIP EDGE X_SD190EWCTE-FT X_SUP,10328710,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2256.00,676.80,958.80,1917.60,,1394.21,,,percent of total billed charges,,,,,,,,service not payable,1100.93,,,percent of total billed charges,,,1137.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,958.80,,,percent of total billed charges,,,,,,,,,1692.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1128.0,,,percent of total billed charges,,,,,,,,service not payable,1692.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1917.60,,,percent of total billed charges,,,1037.76,,,percent of total billed charges,,,,,,,,,1466.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1466.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH EDGE MEDIAL FIRM TIP,10328711,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,4242.00,1272.60,1802.85,3605.70,,2621.56,,,percent of total billed charges,,,,,,,,service not payable,2070.10,,,percent of total billed charges,,,2139.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1802.85,,,percent of total billed charges,,,,,,,,,3181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2121.0,,,percent of total billed charges,,,,,,,,service not payable,3181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3605.70,,,percent of total billed charges,,,1951.32,,,percent of total billed charges,,,,,,,,,2757.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2757.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER MED FIRM TIP EXT CHANNEL X_SDMEWCTE-FT X_,10328712,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2256.00,676.80,958.80,1917.60,,1394.21,,,percent of total billed charges,,,,,,,,service not payable,1100.93,,,percent of total billed charges,,,1137.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,958.80,,,percent of total billed charges,,,,,,,,,1692.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1128.0,,,percent of total billed charges,,,,,,,,service not payable,1692.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1917.60,,,percent of total billed charges,,,1037.76,,,percent of total billed charges,,,,,,,,,1466.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1466.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE CRV 0.035INX300CM,10328717,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.23,558.45,,406.03,,,percent of total billed charges,,,,,,,,service not payable,320.62,,,percent of total billed charges,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.23,,,percent of total billed charges,,,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE CRV 0.032INX260CM,10328718,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,143.00,42.90,60.77,121.55,,88.37,,,percent of total billed charges,,,,,,,,service not payable,69.78,,,percent of total billed charges,,,72.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,,,service not payable,107.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE CRV 0.035INX260CM,10328719,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,143.00,42.90,60.77,121.55,,88.37,,,percent of total billed charges,,,,,,,,service not payable,69.78,,,percent of total billed charges,,,72.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,,,service not payable,107.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 8.5F 71CM,10328720,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,2161.15,,,percent of total billed charges,,,,,,,,service not payable,1706.54,,,percent of total billed charges,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,2273.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2273.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PACING J TIP 5F 90CM,10328721,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,608.11,,,percent of total billed charges,,,,,,,,service not payable,480.19,,,percent of total billed charges,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,639.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,639.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PACING STR TIP 5F 90CM,10328722,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,608.11,,,percent of total billed charges,,,,,,,,service not payable,480.19,,,percent of total billed charges,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,639.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,639.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 15F 33CM,10328725,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.13,2044.25,,1486.29,,,percent of total billed charges,,,,,,,,service not payable,1173.64,,,percent of total billed charges,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.13,,,percent of total billed charges,,,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB SIGMA PFC SZ4 10MM,10329017,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9844.00,2953.20,3819.47,8367.40,,4823.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4134.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3819.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4183.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7383.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4922.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8367.40,,,percent of total billed charges,,,4429.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB SIGMA PFC SZ4 10MM,10329017,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9844.00,2953.20,4134.48,8367.40,,4823.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4134.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4965.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4183.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7383.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4922.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7383.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8367.40,,,percent of total billed charges,,,4528.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 8H STRT X_425758 X_STRYKER,10329450,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2251.00,675.30,873.39,1913.35,,,,,,,,,,,,,,,,,,,,873.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,956.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1688.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1125.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1913.35,,,percent of total billed charges,,,1012.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 8H STRT X_425758 X_STRYKER,10329450,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2251.00,675.30,956.67,1913.35,,,,,,,,,,,,,service not payable,,,,,,,1135.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,956.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1688.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1125.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1688.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1913.35,,,percent of total billed charges,,,1035.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET 52MM X_709-04-52E X_STRYKER,10329452,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET 52MM X_709-04-52E X_STRYKER,10329452,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC PRESTIGE 5MMX14MM X_6972450 X_MEDTRONIC USA I,10329454,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,15901.00,4770.30,6169.59,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6169.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13515.85,,,percent of total billed charges,,,7155.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC PRESTIGE 5MMX14MM X_6972450 X_MEDTRONIC USA I,10329454,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,15901.00,4770.30,6678.42,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8020.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13515.85,,,percent of total billed charges,,,7314.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD SPINAL CORD 65MM,10329455,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,20325.00,6097.50,7886.10,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7886.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17276.25,,,percent of total billed charges,,,9146.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD SPINAL CORD 65MM,10329455,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,20325.00,6097.50,8536.5,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10251.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17276.25,,,percent of total billed charges,,,9349.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING HYDROCOLLOID SNAP 2IN,10329456,CDM,0272,RC,A6234,HCPCS,,,,,,outpatient,facility,,,39.00,11.70,16.57,33.15,,24.10,,,percent of total billed charges,,,,,,,,service not payable,19.03,,,percent of total billed charges,,,19.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,service not payable,29.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,33.15,,,percent of total billed charges,,,17.94,,,percent of total billed charges,,,,,,,,,25.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,25.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VALVED CENTESIS 5F 10CM,10329458,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,132.00,39.60,56.10,112.2,,81.58,,,percent of total billed charges,,,,,,,,service not payable,64.42,,,percent of total billed charges,,,66.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,,,,,,,99.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,66.0,,,percent of total billed charges,,,,,,,,service not payable,99.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,112.2,,,percent of total billed charges,,,60.72,,,percent of total billed charges,,,,,,,,,85.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,85.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BIOCOMP INTERF 9X23MM,10329459,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIOCOMP INTERF 9X23MM,10329459,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ7 7MM,10329460,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ7 7MM,10329460,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST GEL HP 750ML,10329461,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST GEL HP 750ML,10329461,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 10X11X40 12DEG X_5201402 X_NUVASI,10329474,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 10X11X40 12DEG X_5201402 X_NUVASI,10329474,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ARMADA 5.5X30MM X_8455530 X_NUVASIVE,10329475,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ARMADA 5.5X30MM X_8455530 X_NUVASIVE,10329475,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR 4H ARMADA ASF X_8452445 X_NUVASIVE,10329476,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR 4H ARMADA ASF X_8452445 X_NUVASIVE,10329476,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL TRIDENT 54MM E X_709-04-54E X_STRYKER,10329477,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL TRIDENT 54MM E X_709-04-54E X_STRYKER,10329477,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM PICO 7 WOUND VAC X_66022003 X_SMITH NEPHEW,10329591,CDM,0272,RC,A6550,HCPCS,,,,,,outpatient,facility,,,1454.00,436.20,617.95,1235.90,,898.57,,,percent of total billed charges,,,,,,,,service not payable,709.55,,,percent of total billed charges,,,733.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,617.95,,,percent of total billed charges,,,,,,,,,1090.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,727.0,,,percent of total billed charges,,,,,,,,service not payable,1090.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1235.90,,,percent of total billed charges,,,668.84,,,percent of total billed charges,,,,,,,,,945.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,945.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CORONARY MICROGLIDE 150CM,10329594,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER PFO CRV 45D 8F 25MM X_9-PFO-025 X_ABBOTT,10329597,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,31144.00,9343.20,12083.87,26472.40,,15260.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13080.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12083.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13236.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23358.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15572.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26472.40,,,percent of total billed charges,,,14014.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER PFO CRV 45D 8F 25MM X_9-PFO-025 X_ABBOTT,10329597,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,31144.00,9343.20,13080.48,26472.40,,15260.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13080.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15709.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13236.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23358.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15572.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23358.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26472.40,,,percent of total billed charges,,,14326.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER PFO CRV 45D 9F 35MM X_9-PFO-035 X_ABBOTT,10329598,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,31144.00,9343.20,12083.87,26472.40,,15260.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13080.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12083.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13236.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23358.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15572.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26472.40,,,percent of total billed charges,,,14014.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER PFO CRV 45D 9F 35MM X_9-PFO-035 X_ABBOTT,10329598,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,31144.00,9343.20,13080.48,26472.40,,15260.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13080.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15709.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13236.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23358.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15572.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23358.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26472.40,,,percent of total billed charges,,,14326.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 4MM,10329599,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 4MM,10329599,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 5MM,10329600,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 5MM,10329600,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 6MM,10329601,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 6MM,10329601,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 7MM,10329602,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 7MM,10329602,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 8MM,10329603,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 8MM,10329603,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 9MM,10329604,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 9MM,10329604,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 6F 10MM,10329605,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 6F 10MM,10329605,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 7F 13MM,10329606,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 7F 13MM,10329606,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 7F 14MM,10329607,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 7F 14MM,10329607,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 7F 16MM,10329608,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 7F 16MM,10329608,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 8F 18MM,10329609,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 8F 18MM,10329609,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 8F 19MM,10329610,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 8F 19MM,10329610,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 8F 20MM,10329611,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 8F 20MM,10329611,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 12F 32MM,10329612,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 12F 32MM,10329612,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 12F 34MM,10329613,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 12F 34MM,10329613,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 12F 36MM,10329614,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 12F 36MM,10329614,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SEPTAL 45D 12F 38MM,10329615,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SEPTAL 45D 12F 38MM,10329615,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER SPTL CRF 45D 8F 35MM,10329616,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,23014.00,6904.20,8929.43,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8929.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19561.90,,,percent of total billed charges,,,10356.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER SPTL CRF 45D 8F 35MM,10329616,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,23014.00,6904.20,9665.88,19561.90,,11276.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11608.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9780.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17260.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11507.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17260.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19561.90,,,percent of total billed charges,,,10586.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 4MM,10329617,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 4MM,10329617,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 6MM,10329618,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 6MM,10329618,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 8MM,10329619,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 8MM,10329619,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 10MM,10329620,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 10MM,10329620,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 12MM,10329621,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 12MM,10329621,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 14MM,10329622,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 14MM,10329622,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 16MM,10329623,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 16MM,10329623,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER MUSCULAR VSD 18MM,10329624,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,29366.00,8809.80,11394.01,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11394.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24961.10,,,percent of total billed charges,,,13214.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER MUSCULAR VSD 18MM,10329624,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,29366.00,8809.80,12333.72,24961.10,,14389.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12333.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14812.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12480.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22024.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14683.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22024.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24961.10,,,percent of total billed charges,,,13508.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 5F 5X4MM,10329625,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 5F 5X4MM,10329625,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 6F 6X4MM,10329626,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 6F 6X4MM,10329626,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 6F 8X6MM,10329627,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 6F 8X6MM,10329627,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 6F 10X8MM,10329628,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 6F 10X8MM,10329628,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 7F 12X10MM,10329629,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 7F 12X10MM,10329629,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 4F 3X9X4.25MM,10329630,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 4F 3X9X4.25MM,10329630,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 4F 3X9X6.25MM,10329631,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 4F 3X9X6.25MM,10329631,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 4F 4X10X4.25MM,10329632,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 4F 4X10X4.25MM,10329632,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 4F 4X10X6.25MM,10329633,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 4F 4X10X6.25MM,10329633,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 5F 5X11X4.25MM,10329634,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 5F 5X11X4.25MM,10329634,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 5F 5X11X6.25MM,10329635,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 5F 5X11X6.25MM,10329635,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 5F 6X12X4.25MM,10329636,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 5F 6X12X4.25MM,10329636,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DUCT 5F 6X12X6.25MM,10329637,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,14959.00,4487.70,5804.09,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5804.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12715.15,,,percent of total billed charges,,,6731.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DUCT 5F 6X12X6.25MM,10329637,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,14959.00,4487.70,6282.78,12715.15,,7329.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7545.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6357.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11219.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11219.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12715.15,,,percent of total billed charges,,,6881.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SIZING 6F 20MMX70CM,10329638,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1891.00,567.30,803.67,1607.35,,1168.64,,,percent of total billed charges,,,,,,,,service not payable,922.81,,,percent of total billed charges,,,953.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,803.67,,,percent of total billed charges,,,,,,,,,1418.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,945.5,,,percent of total billed charges,,,,,,,,service not payable,1418.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1607.35,,,percent of total billed charges,,,869.86,,,percent of total billed charges,,,,,,,,,1229.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1229.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SIZING 7F 24MMX70CM,10329639,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1891.00,567.30,803.67,1607.35,,1168.64,,,percent of total billed charges,,,,,,,,service not payable,922.81,,,percent of total billed charges,,,953.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,803.67,,,percent of total billed charges,,,,,,,,,1418.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,945.5,,,percent of total billed charges,,,,,,,,service not payable,1418.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1607.35,,,percent of total billed charges,,,869.86,,,percent of total billed charges,,,,,,,,,1229.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1229.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SIZING 8F 34MMX70CM,10329640,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1891.00,567.30,803.67,1607.35,,1168.64,,,percent of total billed charges,,,,,,,,service not payable,922.81,,,percent of total billed charges,,,953.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,803.67,,,percent of total billed charges,,,,,,,,,1418.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,945.5,,,percent of total billed charges,,,,,,,,service not payable,1418.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1607.35,,,percent of total billed charges,,,869.86,,,percent of total billed charges,,,,,,,,,1229.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1229.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 3MM J TIP 7.5MM,10329641,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,199.61,,,percent of total billed charges,,,,,,,,service not payable,157.62,,,percent of total billed charges,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE J TIP 1.5MM,10329642,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,199.61,,,percent of total billed charges,,,,,,,,service not payable,157.62,,,percent of total billed charges,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE J TIP 6MM,10329643,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,199.61,,,percent of total billed charges,,,,,,,,service not payable,157.62,,,percent of total billed charges,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE J TIP SOFT 6MM,10329644,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,199.61,,,percent of total billed charges,,,,,,,,service not payable,157.62,,,percent of total billed charges,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MEASURE SEPTAL OCCLUDER,10329645,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,46.00,13.80,17.85,39.10,,,,,,,,,,,,,,,,,,,,17.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,34.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.10,,,percent of total billed charges,,,20.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MEASURE SEPTAL OCCLUDER,10329645,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,46.00,13.80,19.55,39.10,,,,,,,,,,,,,service not payable,,,,,,,23.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,19.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,34.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,23.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,34.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,39.10,,,percent of total billed charges,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELIV SYS 6F 45D 60CM,10329646,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELIV SYS 6F 45D 60CM,10329646,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELIV SYS 7F 45D 60CM,10329647,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELIV SYS 7F 45D 60CM,10329647,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELIV SYS 7F 45D 80CM,10329648,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELIV SYS 7F 45D 80CM,10329648,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELIV SYS 8F 45D 60CM,10329649,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELIV SYS 8F 45D 60CM,10329649,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELIV SYS 9F 45D 80CM,10329650,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELIV SYS 9F 45D 80CM,10329650,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 10F 45D 80CM,10329651,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 10F 45D 80CM,10329651,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 5F 180D 60CM,10329652,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 5F 180D 60CM,10329652,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 6F 180D 60CM,10329653,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 6F 180D 60CM,10329653,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 6F 180D 80CM,10329654,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 6F 180D 80CM,10329654,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 7F 180D 80CM,10329655,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 7F 180D 80CM,10329655,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 8F 180D 80CM,10329656,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 8F 180D 80CM,10329656,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELV SYS 9F 180D 80CM,10329657,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELV SYS 9F 180D 80CM,10329657,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 9F 45D 80CM,10329658,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 9F 45D 80CM,10329658,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 12F 45D 80CM,10329659,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 12F 45D 80CM,10329659,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 6F 180D 80CM,10329660,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 6F 180D 80CM,10329660,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 8F 180D 80CM,10329661,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 8F 180D 80CM,10329661,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 4F 90D 60CM,10329662,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 4F 90D 60CM,10329662,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 4F 90D 80CM,10329663,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 4F 90D 80CM,10329663,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 5F 90D 60CM,10329664,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 5F 90D 60CM,10329664,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER EXCH SYS 5F 90D 80CM,10329665,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER EXCH SYS 5F 90D 80CM,10329665,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DLV TORQUE VUE 5F 120CM,10329666,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DLV TORQUE VUE 6F 120CM,10329667,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DLV TORQUE VUE 7F 120CM,10329668,CDM,0272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,2212.44,,,percent of total billed charges,,,,,,,,service not payable,1747.04,,,percent of total billed charges,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2327.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER VOICE BLOMSNGR 20F,10329669,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER VOICE BLOMSNGR 20F,10329669,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,34.58,534.65,,,,,,,,49.53,,,fee schedule,,,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,471.75,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,471.75,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
Clorazepate Level,10330,CDM,0300,RC,80346,CPT,,,,,,outpatient,facility,,,88.00,26.40,31.17,74.80,,54.38,,,percent of total billed charges,,,,,,,,service not payable,43.30,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,31.17,,,fee schedule,,,,,,,,,66.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,36.66,,,fee schedule,,,,,,,,service not payable,66.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,74.80,,,percent of total billed charges,,,40.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Clorazepate Level,10330,CDM,0300,RC,80346,CPT,2040,EAPG,,,,outpatient,facility,,,88.00,26.40,16.44,84.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,72.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Clorazepate Level,10330,CDM,0300,RC,G0480,HCPCS,,,,,,outpatient,facility,,,97.00,29.10,44.62,238.64,,59.95,,,percent of total billed charges,,,95.06,,,fee schedule,,,47.72,,,fee schedule,,,238.64,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,200.79,,,fee schedule,,,97.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",96.96,,,fee schedule,,,219.22,,,fee schedule,,,,,,,,,95.06,,,fee schedule,,,,,,,,,147.02,,,fee schedule,,,197.88,,,fee schedule,,,72.75,,,percent of total billed charges,,,95.06,,,fee schedule,,,97.0,,,fee schedule,,,96.96,,,fee schedule,,,172.90,,,fee schedule,,,95.06,,,fee schedule,,,72.75,,,percent of total billed charges,,,,,,,,,96.96,,,fee schedule,,,,,,,,,82.45,,,percent of total billed charges,,,44.62,,,percent of total billed charges,,,,,,,,,125.87,,,fee schedule,,,95.06,,,fee schedule,,,,,,,,,111.0,,,fee schedule,,,95.06,,,fee schedule,,,,,,,,,95.06,,,fee schedule,,,,,,,,
Clorazepate Level,10330,CDM,0300,RC,G0480,HCPCS,2041,EAPG,,,,outpatient,facility,,,97.00,29.10,82.28,141.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,120.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BASE PLT TIB UNCMNT 2 42X64MM,10330043,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE PLT TIB UNCMNT 2 42X64MM,10330043,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART BCS XPLE SZ7-8 LT,10330044,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS XPLE SZ7-8 LT,10330044,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II LT SZ8,10330045,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II LT SZ8,10330045,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH METACROSS 8X40MM 135CM,10330046,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,385.63,,,percent of total billed charges,,,,,,,,service not payable,304.51,,,percent of total billed charges,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VNTRLGHT ST 6IN CIRCLE,10330047,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VNTRLGHT ST 6IN CIRCLE,10330047,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VNTRLGHT ST 7X9IN,10330048,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VNTRLGHT ST 7X9IN,10330048,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH VNTRLGHT ST 8X10IN,10330049,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4066.00,1219.80,1577.61,3456.10,,,,,,,,,,,,,,,,,,,,1577.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1728.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3049.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3456.10,,,percent of total billed charges,,,1829.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH VNTRLGHT ST 8X10IN,10330049,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4066.00,1219.80,1728.05,3456.10,,,,,,,,,,,,,service not payable,,,,,,,2050.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1728.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3049.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3049.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3456.10,,,percent of total billed charges,,,1870.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 26MM PERFORM P,10330050,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 26MM PERFORM P,10330050,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST CPG GEL HP 750ML,10330051,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4656.00,1396.80,1806.53,3957.60,,,,,,,,,,,,,,,,,,,,1806.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1978.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3492.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2328.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.60,,,percent of total billed charges,,,2095.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST CPG GEL HP 750ML,10330051,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4656.00,1396.80,1978.8,3957.60,,,,,,,,,,,,,service not payable,,,,,,,2348.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1978.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3492.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2328.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3492.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3957.60,,,percent of total billed charges,,,2141.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT GEL ALLOSYNC DMB CB 5 CC,10330052,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT GEL ALLOSYNC DMB CB 5 CC,10330052,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T10 FT 2.7MMXL24MM X_657124 X_STRYKER,10330053,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T10 FT 2.7MMXL24MM X_657124 X_STRYKER,10330053,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T10 FT 2.7MMXL28MM X_657128 X_STRYKER,10330054,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T10 FT 2.7MMXL28MM X_657128 X_STRYKER,10330054,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T10 FT 2.7MMXL44MM X_657144 X_STRYKER,10330055,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T10 FT 2.7MMXL44MM X_657144 X_STRYKER,10330055,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T10 FT 2.7MMXL65MM X_657165 X_STRYKER,10330056,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T10 FT 2.7MMXL65MM X_657165 X_STRYKER,10330056,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT GLENOID CORTILCK MD SMPLICT 52X19 X_DWK404,10330058,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10282.00,3084.60,3989.42,8739.70,,5038.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4318.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3989.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4369.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7711.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5141.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8739.70,,,percent of total billed charges,,,4626.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT GLENOID CORTILCK MD SMPLICT 52X19 X_DWK404,10330058,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10282.00,3084.60,4318.44,8739.70,,5038.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4318.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5186.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4369.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7711.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5141.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7711.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8739.70,,,percent of total billed charges,,,4729.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 52X19MM,10330059,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11782.00,3534.60,4571.42,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4571.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10014.70,,,percent of total billed charges,,,5301.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 52X19MM,10330059,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11782.00,3534.60,4948.44,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5942.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10014.70,,,percent of total billed charges,,,5419.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CARTILAGE VIABLE BIO,10331068,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16228.00,4868.40,6296.46,13793.80,,7951.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6815.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6296.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6896.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13793.80,,,percent of total billed charges,,,7302.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT CARTILAGE VIABLE BIO,10331068,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16228.00,4868.40,6815.76,13793.80,,7951.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6815.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8185.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6896.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12171.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12171.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13793.80,,,percent of total billed charges,,,7464.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RAD POST TI 5.5X120MM,10331069,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RAD POST TI 5.5X120MM,10331069,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST LOCKING 2.0X10MM,10331070,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1142.00,342.60,443.10,970.70,,,,,,,,,,,,,,,,,,,,443.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,856.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,571.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.70,,,percent of total billed charges,,,513.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST LOCKING 2.0X10MM,10331070,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1142.00,342.60,485.35,970.70,,,,,,,,,,,,,service not payable,,,,,,,576.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,485.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,856.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,571.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,856.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,970.70,,,percent of total billed charges,,,525.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST LOCKING 2.0X14MM,10331071,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1142.00,342.60,443.10,970.70,,,,,,,,,,,,,,,,,,,,443.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,856.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,571.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.70,,,percent of total billed charges,,,513.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST LOCKING 2.0X14MM,10331071,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1142.00,342.60,485.35,970.70,,,,,,,,,,,,,service not payable,,,,,,,576.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,485.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,856.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,571.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,856.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,970.70,,,percent of total billed charges,,,525.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ULNA LCP 7H DIST 46MM,10331072,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4701.00,1410.30,1823.99,3995.85,,,,,,,,,,,,,,,,,,,,1823.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3525.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2350.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3995.85,,,percent of total billed charges,,,2115.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ULNA LCP 7H DIST 46MM,10331072,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4701.00,1410.30,1997.92,3995.85,,,,,,,,,,,,,service not payable,,,,,,,2371.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1997.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3525.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2350.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3525.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3995.85,,,percent of total billed charges,,,2162.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST LOCKING 2.0X18MM,10331073,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1142.00,342.60,443.10,970.70,,,,,,,,,,,,,,,,,,,,443.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,856.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,571.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.70,,,percent of total billed charges,,,513.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST LOCKING 2.0X18MM,10331073,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1142.00,342.60,485.35,970.70,,,,,,,,,,,,,service not payable,,,,,,,576.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,485.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,856.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,571.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,856.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,970.70,,,percent of total billed charges,,,525.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BRD CONT SS 11H 4.5X213,10331074,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1176.00,352.80,456.29,999.60,,,,,,,,,,,,,,,,,,,,456.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,499.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,882.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,588.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,999.60,,,percent of total billed charges,,,529.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BRD CONT SS 11H 4.5X213,10331074,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1176.00,352.80,499.80,999.60,,,,,,,,,,,,,service not payable,,,,,,,593.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,499.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,882.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,588.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,882.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,999.60,,,percent of total billed charges,,,540.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE FIRSTPASS MINI X_7229-0128 X_SMITH N,10331076,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE FIRSTPASS MINI X_7229-0128 X_SMITH N,10331076,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CENTERCROSS ULTRA 3F 4MM X_UC-0100 X_EKOS COR,10331371,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.17,3052.35,,2219.24,,,percent of total billed charges,,,,,,,,service not payable,1752.41,,,percent of total billed charges,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.17,,,percent of total billed charges,,,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,2334.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2334.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WOLVERINE CB OTW 3.50X10MM,10331375,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3324.00,997.20,1412.7,2825.40,,2054.23,,,percent of total billed charges,,,,,,,,service not payable,1622.11,,,percent of total billed charges,,,1676.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,,,,,,,2493.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,2493.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2825.40,,,percent of total billed charges,,,1529.04,,,percent of total billed charges,,,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE EBU3.75 SH 7F 90CM X_LA7EBU375SH X_MEDT,10331376,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE EBU4 SH 7F 100CM,10331377,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE LEFT2 7F 90CM,10331378,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL2 SH 7F 90CM X_LA7AL20SH X_MEDTRONIC,10331379,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL.75 SH 8F 90CM,10331380,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL1 SH 8F 90CM,10331381,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE X BACK UP3 8F 90CM,10331382,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE EBU3 SH 8F 90CM X_LA8EBU30SH X_MEDTRONI,10331383,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL.75 8F 90CM,10331384,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL2 SH 8F 90CM X_LA8AL20SH X_MEDTRONIC,10331385,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCKER EB COHEN TIP 9FR 65CM,10331389,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1586.00,475.80,615.37,1348.10,,,,,,,,,,,,,,,,,,,,615.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.10,,,percent of total billed charges,,,713.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCKER EB COHEN TIP 9FR 65CM,10331389,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1586.00,475.80,674.05,1348.10,,,,,,,,,,,,,service not payable,,,,,,,799.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1189.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,793.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1189.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1348.10,,,percent of total billed charges,,,729.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDING 1.4-2.6F L150CM,10331390,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,2296.49,,,percent of total billed charges,,,,,,,,service not payable,1813.41,,,percent of total billed charges,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,2415.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2415.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Lutonix .018 DCB 130cm 7x80mm_Becton Dickinson_LX1,10331391,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4536.00,1360.80,1927.8,3855.60,,2803.25,,,percent of total billed charges,,,,,,,,service not payable,2213.57,,,percent of total billed charges,,,2287.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1927.8,,,percent of total billed charges,,,,,,,,,3402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2268.0,,,percent of total billed charges,,,,,,,,service not payable,3402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3855.60,,,percent of total billed charges,,,2086.56,,,percent of total billed charges,,,,,,,,,2948.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2948.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON LUTONIX 35 DCB 7X100MM,10331392,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON LUTONIX 35 DCB 7X150MM,10331393,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON LUTONIX 35 DCB 7X220MM,10331394,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2786.30,5572.60,,4051.61,,,percent of total billed charges,,,,,,,,service not payable,3199.33,,,percent of total billed charges,,,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3278.0,,,percent of total billed charges,,,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,4261.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4261.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 2X100MM X_US14150210 X,10331395,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 2X150MM X_US14150215 X,10331396,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 2X300MM X_US14150230 X,10331397,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 2.5X80MM X_US141502H8,10331398,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 2.5X150MM X_US141502H1,10331399,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 2.5X300MM X_US141502H3,10331400,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 3X80MM X_US1415038 X_C,10331401,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 3X100MM X_US14150310 X,10331402,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 3X150MM X_US14150315 X,10331403,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON ULTRASCORE 014 3X300MM X_US14150330 X,10331404,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X22MM X_7241-2422 X_SMITH NEPHEW,10331411,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X22MM X_7241-2422 X_SMITH NEPHEW,10331411,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X26MM X_7241-2426 X_SMITH NEPHEW,10331412,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X26MM X_7241-2426 X_SMITH NEPHEW,10331412,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X32MM X_7241-2432 X_SMITH NEPHEW,10331413,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X32MM X_7241-2432 X_SMITH NEPHEW,10331413,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.4X36MM X_7241-2436 X_SMITH NEPHEW,10331414,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,577.00,173.10,223.88,490.45,,,,,,,,,,,,,,,,,,,,223.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.45,,,percent of total billed charges,,,259.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.4X36MM X_7241-2436 X_SMITH NEPHEW,10331414,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,577.00,173.10,245.22,490.45,,,,,,,,,,,,,service not payable,,,,,,,291.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,245.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,490.45,,,percent of total billed charges,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR RT SZ5-6 11MM X_74027253 X_SMITH,10331415,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR RT SZ5-6 11MM X_74027253 X_SMITH,10331415,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II RT SZ 5,10331416,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II RT SZ 5,10331416,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2H SS AR-8958-01S X_ARTHREX INC,10331417,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2H SS AR-8958-01S X_ARTHREX INC,10331417,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR CR SZ7-8 11MM X_71453158 X_SMITH,10331418,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR CR SZ7-8 11MM X_71453158 X_SMITH,10331418,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAV DIST SHT LT SS,10331419,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAV DIST SHT LT SS,10331419,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAV DIST BUTTON,10331420,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAV DIST BUTTON,10331420,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE XSM CC FIX W/O SPIKES X_XS07MT15300 X_SMITH,10331421,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE XSM CC FIX W/O SPIKES X_XS07MT15300 X_SMITH,10331421,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPRO 9MMX15CM 120CM,10331960,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13270.00,3981.00,5148.76,11279.5,,6502.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5573.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5148.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5639.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9952.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6635.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11279.5,,,percent of total billed charges,,,5971.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPRO 9MMX15CM 120CM,10331960,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13270.00,3981.00,5573.40,11279.5,,6502.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5573.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6693.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5639.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9952.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6635.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9952.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11279.5,,,percent of total billed charges,,,6104.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL RP CEM SZ3,10331961,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16614.00,4984.20,6446.23,14121.9,,8140.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6977.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6446.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7060.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12460.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8307.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14121.9,,,percent of total billed charges,,,7476.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL RP CEM SZ3,10331961,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16614.00,4984.20,6977.88,14121.9,,8140.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6977.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8380.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7060.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12460.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8307.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12460.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14121.9,,,percent of total billed charges,,,7642.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.0D 8.5D,10331962,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.0D 8.5D,10331962,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP PATELLA SZ A32 32X36X10MM,10331963,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP PATELLA SZ A32 32X36X10MM,10331963,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BB Ref Eluate each,103322,CDM,0300,RC,86860,CPT,,,,,,outpatient,facility,,,118.00,35.40,38.33,179.01,,72.92,,,percent of total billed charges,,,,,,,,,58.06,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.33,,,fee schedule,,,,,,,,,88.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.08,,,fee schedule,,,,,,,,,88.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.3,,,percent of total billed charges,,,54.28,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
BB Ref Eluate each,103322,CDM,0300,RC,86860,CPT,05672,APC,,,,outpatient,facility,,,118.00,35.40,118.0,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,118.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,118.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
BB Ref Eluate each,103322,CDM,0300,RC,86860,CPT,2043,EAPG,,,,outpatient,facility,,,118.00,35.40,118.0,608.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,517.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,118.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,118.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,124.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,137.08,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE FIB STRT 4H 60MM X_40-20804 X_STRYKER ORTHOP,10332241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1915.00,574.50,743.02,1627.75,,,,,,,,,,,,,,,,,,,,743.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1436.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,957.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1627.75,,,percent of total billed charges,,,861.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB STRT 4H 60MM X_40-20804 X_STRYKER ORTHOP,10332241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1915.00,574.50,813.88,1627.75,,,,,,,,,,,,,service not payable,,,,,,,965.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1436.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,957.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1436.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1627.75,,,percent of total billed charges,,,880.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RADIUS POST 5.5X110MM,10332242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RADIUS POST 5.5X110MM,10332242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Wire Lunderquist .35 X 180cm X_G49228 X_Cook Group,10332244,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,298.00,89.40,126.65,253.30,,184.16,,,percent of total billed charges,,,,,,,,service not payable,145.42,,,percent of total billed charges,,,150.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,126.65,,,percent of total billed charges,,,,,,,,,223.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,149.0,,,percent of total billed charges,,,,,,,,service not payable,223.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,253.30,,,percent of total billed charges,,,137.08,,,percent of total billed charges,,,,,,,,,193.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,193.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 10.5,10332245,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 10.5,10332245,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EP INQ LG 6F DEC 110CM,10332247,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,1333.64,,,percent of total billed charges,,,,,,,,service not payable,1053.10,,,percent of total billed charges,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1402.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EP INQ 6F STEERABLE QUAD,10332248,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,1804.00,541.20,766.70,1533.40,,1114.87,,,percent of total billed charges,,,,,,,,service not payable,880.35,,,percent of total billed charges,,,909.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,766.70,,,percent of total billed charges,,,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,902.0,,,percent of total billed charges,,,,,,,,service not payable,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1533.40,,,percent of total billed charges,,,829.84,,,percent of total billed charges,,,,,,,,,1172.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1172.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PIONEER PLUS 6F 120CM X_PPLUS120 X_PHILIPS HE,10332249,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,9016.00,2704.80,3831.80,7663.60,,5571.89,,,percent of total billed charges,,,,,,,,service not payable,4399.81,,,percent of total billed charges,,,4547.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3831.80,,,percent of total billed charges,,,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4508.0,,,percent of total billed charges,,,,,,,,service not payable,6762.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7663.60,,,percent of total billed charges,,,4147.36,,,percent of total billed charges,,,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Spinal Angiography ea Add Vessel,10332368,CDM,0323,RC,75705,CPT,,,,,,outpatient,facility,,,13728.00,4118.40,272.77,11668.80,,365.56,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,272.77,,,fee schedule,,,6924.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5834.40,,,percent of total billed charges,,,,,,,,,10296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6864.0,,,percent of total billed charges,,,,,,,,,10296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11668.80,,,percent of total billed charges,,,6314.88,,,percent of total billed charges,,,,,,,,,11519.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Spinal Angiography ea Add Vessel,10332368,CDM,0323,RC,75705,CPT,05184,APC,,,,outpatient,facility,,,13728.00,4118.40,4972.31,11906.09,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10905.13,,,fee schedule,,,4972.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5287.57,,,fee schedule,,,11906.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10747.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,4972.31,,,fee schedule,,,5287.57,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,4972.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5287.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,5235.52,,,fee schedule,,,,,,,,
Spinal Angiography ea Add Vessel,10332368,CDM,0323,RC,75705,CPT,280,EAPG,,,,outpatient,facility,,,13728.00,4118.40,6430.47,16406.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16406.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13945.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7392.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,8131.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Spinal Angiography ea Add Vessel,10332369,CDM,0323,RC,75705,CPT,,,,,,outpatient,facility,,,13728.00,4118.40,272.77,11668.80,,365.56,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,272.77,,,fee schedule,,,6924.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5834.40,,,percent of total billed charges,,,,,,,,,10296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6864.0,,,percent of total billed charges,,,,,,,,,10296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11668.80,,,percent of total billed charges,,,6314.88,,,percent of total billed charges,,,,,,,,,11519.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Spinal Angiography ea Add Vessel,10332369,CDM,0323,RC,75705,CPT,05184,APC,,,,outpatient,facility,,,13728.00,4118.40,4972.31,11906.09,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10905.13,,,fee schedule,,,4972.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5287.57,,,fee schedule,,,11906.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10747.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,4972.31,,,fee schedule,,,5287.57,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,4972.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5287.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,5235.52,,,fee schedule,,,,,,,,
Spinal Angiography ea Add Vessel,10332369,CDM,0323,RC,75705,CPT,280,EAPG,,,,outpatient,facility,,,13728.00,4118.40,6430.47,16406.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16406.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13945.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6430.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7392.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,8131.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DEVICE AEROBIKA OPEP X_58-62510 X_341838,10332398,CDM,0271,RC,E0484,HCPCS,,,,,,outpatient,facility,,,249.00,74.70,105.83,211.65,,153.88,,,percent of total billed charges,,,,,,,,service not payable,121.51,,,percent of total billed charges,,,125.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,124.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,124.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,105.83,,,percent of total billed charges,,,,,,,,,186.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,124.5,,,percent of total billed charges,,,,,,,,service not payable,186.75,,,percent of total billed charges,,,,,,,,service not payable,112.05,,,fee schedule,,,,,,,,,211.65,,,percent of total billed charges,,,114.54,,,percent of total billed charges,,,,,,,,,161.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,161.85,,,percent of total billed charges,,,124.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW TWIST OFF 2X14MM,10332479,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2225.00,667.50,863.30,1891.25,,,,,,,,,,,,,,,,,,,,863.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1668.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1112.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1891.25,,,percent of total billed charges,,,1001.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TWIST OFF 2X14MM,10332479,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2225.00,667.50,945.62,1891.25,,,,,,,,,,,,,service not payable,,,,,,,1122.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,945.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1668.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1112.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1668.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1891.25,,,percent of total billed charges,,,1023.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER PRIMO MRI ICD VR,10332480,CDM,0275,RC,C1722,HCPCS,,,,,,inpatient,facility,,,23310.00,6993.00,9044.28,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9790.20,,,percent of total billed charges,,Paid in addition to inpatient services ,9044.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19813.5,,,percent of total billed charges,,,10489.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER PRIMO MRI ICD VR,10332480,CDM,0275,RC,C1722,HCPCS,,,,,,outpatient,facility,,,23310.00,6993.00,9790.20,19813.5,,11421.9,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9790.20,,,percent of total billed charges,,Paid in addition to outpatient services ,11757.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9906.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17482.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11655.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17482.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19813.5,,,percent of total billed charges,,,10722.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRILL PIN CLOSED EYELET X_AR-1595TC X_ARTHREX INC,10332482,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRILL PIN CLOSED EYELET X_AR-1595TC X_ARTHREX INC,10332482,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 7X20X75,10332483,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 BE SHT SZ,10332484,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,30.36,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TRANSFIX 5X6X250MM X_5050-5-250 X_STRYKER ORTH,10332485,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,793.00,237.90,307.68,674.05,,,,,,,,,,,,,,,,,,,,307.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,356.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TRANSFIX 5X6X250MM X_5050-5-250 X_STRYKER ORTH,10332485,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,,,,,,,,,,,,service not payable,,,,,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AXSOS 6H RT 127MM X_627486 X_STRYKER ORTHOPA,10332486,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7522.00,2256.60,2918.54,6393.70,,3685.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3159.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2918.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3196.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5641.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3761.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6393.70,,,percent of total billed charges,,,3384.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AXSOS 6H RT 127MM X_627486 X_STRYKER ORTHOPA,10332486,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7522.00,2256.60,3159.24,6393.70,,3685.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3159.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3794.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3196.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5641.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3761.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5641.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6393.70,,,percent of total billed charges,,,3460.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH 6FR PELUDE IDEAL RADIAL,10332488,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,service not payable,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SS 6.5X85MM TL20MM X_326085 X_STRYKER O,10332494,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SS 6.5X85MM TL20MM X_326085 X_STRYKER O,10332494,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDEWIRE GT .016 180CM DB ANG,10332495,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1464.00,439.20,622.20,1244.40,,904.75,,,percent of total billed charges,,,,,,,,service not payable,714.43,,,percent of total billed charges,,,738.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,622.20,,,percent of total billed charges,,,,,,,,,1098.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,732.0,,,percent of total billed charges,,,,,,,,service not payable,1098.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1244.40,,,percent of total billed charges,,,673.44,,,percent of total billed charges,,,,,,,,,951.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,951.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BB Ref Rh Phenotype Complete,103325,CDM,0300,RC,86906,CPT,,,,,,outpatient,facility,,,101.00,30.30,7.52,85.85,,24.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,18.57,,,fee schedule,,,16.16,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.12,,,fee schedule,,,,,,,,,75.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.9,,,fee schedule,,,,,,,,,75.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.85,,,percent of total billed charges,,,46.46,,,percent of total billed charges,,,,,,,,,8.53,,,fee schedule,,,,,,,,,,,,,,,7.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
BB Ref Rh Phenotype Complete,103325,CDM,0300,RC,86906,CPT,05732,APC,,,,outpatient,facility,,,101.00,30.30,36.11,86.44,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,79.18,,,fee schedule,,,36.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",38.39,,,fee schedule,,,86.44,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,78.03,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,36.11,,,fee schedule,,,38.39,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,,,,,,,36.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",38.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,37.64,,,fee schedule,,,,,,,,,38.01,,,fee schedule,,,,,,,,
BB Ref Rh Phenotype Complete,103325,CDM,0300,RC,86906,CPT,486,EAPG,,,,outpatient,facility,,,101.00,30.30,5.24,73.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,62.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH TEMPO 135D 038IN 4F 125CM,10332895,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,243.49,,,percent of total billed charges,,,,,,,,service not payable,192.27,,,percent of total billed charges,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,256.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,256.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F TEMPO AQUA .038IN 125,10332896,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,243.49,,,percent of total billed charges,,,,,,,,service not payable,192.27,,,percent of total billed charges,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,256.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,256.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO J-CRV 5F 65CM,10332897,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,139.00,41.70,59.08,118.15,,85.90,,,percent of total billed charges,,,,,,,,service not payable,67.83,,,percent of total billed charges,,,70.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.08,,,percent of total billed charges,,,,,,,,,104.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,69.5,,,percent of total billed charges,,,,,,,,service not payable,104.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,118.15,,,percent of total billed charges,,,63.94,,,percent of total billed charges,,,,,,,,,90.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,90.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO TEMPO 5F 80CM,10332898,CDM,0278,RC,C1725,HCPCS,,,,,,inpatient,facility,,,139.00,41.70,53.93,118.15,,,,,,,,,,,,,,,,,,,,53.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,104.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.15,,,percent of total billed charges,,,62.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TEMPO 5F 80CM,10332898,CDM,0278,RC,C1725,HCPCS,,,,,,outpatient,facility,,,139.00,41.70,59.07,118.15,,,,,,,,,,,,,service not payable,,,,,,,70.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,104.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,69.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,104.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,118.15,,,percent of total billed charges,,,63.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRUE 11F 18MMX4.5CM 110CM,10332899,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRUE 11F 20MMX4.5CM 110CM,10332900,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRUE 14F 28MMX4.5CM 110CM,10332901,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRUE 12F 22MMX4.5CM 110CM,10332902,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRUE 12F 24MMX4.5CM 110CM,10332903,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRUE 13F 26MMX4.5CM 110CM,10332904,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER OCCL TORNUS 2.1F 135CM X_AT24135 X_ASAHI,10332905,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,1891.7,,,percent of total billed charges,,,,,,,,service not payable,1493.77,,,percent of total billed charges,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,1989.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1989.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER OCCL TORNUS 2.6F 135CM X_AT35135 X_ASAHI,10332906,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,1891.7,,,percent of total billed charges,,,,,,,,service not payable,1493.77,,,percent of total billed charges,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,1989.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1989.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ALPHA PROGREAT 2.0F 130CM,10332907,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DABRA 5F X_1222-5000-01 X_RA MEDICAL SYST,10332908,CDM,0272,RC,C1885,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ALPHA PROGREAT 2.0F 150CM,10332910,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 4X34MM X_AR-8940-34 X_ARTHREX INC,10332911,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 4X34MM X_AR-8940-34 X_ARTHREX INC,10332911,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CANC TI 4.0X30MM,10332912,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CANC TI 4.0X30MM,10332912,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PLANTAR LAPIDUS SHORT LT,10332913,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PLANTAR LAPIDUS SHORT LT,10332913,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PICC 1LUM 1.9FR X_384539,10333144,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,298.00,89.40,126.65,253.30,,184.16,,,percent of total billed charges,,,,,,,,service not payable,145.42,,,percent of total billed charges,,,150.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,126.65,,,percent of total billed charges,,,,,,,,,223.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,149.0,,,percent of total billed charges,,,,,,,,service not payable,223.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,253.30,,,percent of total billed charges,,,137.08,,,percent of total billed charges,,,,,,,,,193.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,193.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PICC 2LUM 1.9FR X_43304,10333146,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,472.00,141.60,200.60,401.20,,291.70,,,percent of total billed charges,,,,,,,,service not payable,230.34,,,percent of total billed charges,,,238.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,200.60,,,percent of total billed charges,,,,,,,,,354.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,236.0,,,percent of total billed charges,,,,,,,,service not payable,354.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,401.20,,,percent of total billed charges,,,217.12,,,percent of total billed charges,,,,,,,,,306.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,306.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPR CAN 22MM X_A-5780.22/1 X_MEDARTIS,10333263,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1763.00,528.90,684.04,1498.55,,,,,,,,,,,,,,,,,,,,684.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,749.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1322.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,881.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1498.55,,,percent of total billed charges,,,793.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPR CAN 22MM X_A-5780.22/1 X_MEDARTIS,10333263,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1763.00,528.90,749.27,1498.55,,,,,,,,,,,,,service not payable,,,,,,,889.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,749.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1322.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,881.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1322.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1498.55,,,percent of total billed charges,,,810.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K-WIRE 100MM X_A-5040.10/1 X_MEDARTIS,10333264,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,148.00,44.40,57.42,125.8,,,,,,,,,,,,,,,,,,,,57.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,66.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K-WIRE 100MM X_A-5040.10/1 X_MEDARTIS,10333264,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,,,,,,,,,,,,service not payable,,,,,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH TOUR GD 7FX_MMX90CM X_TG0709009 X_GORE MEDI,10333265,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,1553.65,,,percent of total billed charges,,,,,,,,service not payable,1226.83,,,percent of total billed charges,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1634.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL HEX 12X2.7MM,10333266,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4574.00,1372.20,1774.71,3887.90,,,,,,,,,,,,,,,,,,,,1774.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.90,,,percent of total billed charges,,,2058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL HEX 12X2.7MM,10333266,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4574.00,1372.20,1943.95,3887.90,,,,,,,,,,,,,service not payable,,,,,,,2307.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1943.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3887.90,,,percent of total billed charges,,,2104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 9FX9MMX120CM X_VBH0901002A X_GORE ME,10333267,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 9FX9MMX120CM X_VBH0901002A X_GORE ME,10333267,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH NEURON DELIV MP 6F 6X105,10333268,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,1755.74,,,percent of total billed charges,,,,,,,,service not payable,1386.41,,,percent of total billed charges,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1846.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL 4.5X28MM X_7112-9228 X_SMITH NEPHEW,10333269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,110.00,33.00,42.68,93.5,,,,,,,,,,,,,,,,,,,,42.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL 4.5X28MM X_7112-9228 X_SMITH NEPHEW,10333269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,110.00,33.00,46.75,93.5,,,,,,,,,,,,,service not payable,,,,,,,55.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,46.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,55.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,82.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,93.5,,,percent of total billed charges,,,50.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE AMBI CHSP 5SL 120MM 140DEG X_121137 X_SMITH,10333270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2009.00,602.70,779.49,1707.65,,,,,,,,,,,,,,,,,,,,779.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.65,,,percent of total billed charges,,,904.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE AMBI CHSP 5SL 120MM 140DEG X_121137 X_SMITH,10333270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2009.00,602.70,853.82,1707.65,,,,,,,,,,,,,service not payable,,,,,,,1013.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,853.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1506.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1004.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1506.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1707.65,,,percent of total billed charges,,,924.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE JAG ANG REV 0.025FR,10333271,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1088.00,326.40,462.40,924.80,,672.38,,,percent of total billed charges,,,,,,,,service not payable,530.94,,,percent of total billed charges,,,548.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,462.40,,,percent of total billed charges,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,544.0,,,percent of total billed charges,,,,,,,,service not payable,816.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,924.80,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,,,,,,,707.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,707.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE JAG STR REV 0.025FR,10333272,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1088.00,326.40,462.40,924.80,,672.38,,,percent of total billed charges,,,,,,,,service not payable,530.94,,,percent of total billed charges,,,548.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,462.40,,,percent of total billed charges,,,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,544.0,,,percent of total billed charges,,,,,,,,service not payable,816.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,924.80,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,,,,,,,707.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,707.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CROWN UNITEK SS PRIM UR3 X_5040456 X_PATTERSON DEN,10333276,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM UR3 X_5040456 X_PATTERSON DEN,10333276,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM UR3 X_5040456 X_PATTERSON DEN,10333276,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM UR4 X_5040498 X_PATTERSON DEN,10333277,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM UR4 X_5040498 X_PATTERSON DEN,10333277,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM UR4 X_5040498 X_PATTERSON DEN,10333277,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM UR5 X_5040530 X_PATTERSON DEN,10333278,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM UR5 X_5040530 X_PATTERSON DEN,10333278,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM UR5 X_5040530 X_PATTERSON DEN,10333278,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM UL3 X_5040464 X_PATTERSON DEN,10333279,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM UL3 X_5040464 X_PATTERSON DEN,10333279,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM UL3 X_5040464 X_PATTERSON DEN,10333279,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM UL4 X_5040506 X_PATTERSON DEN,10333280,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM UL4 X_5040506 X_PATTERSON DEN,10333280,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM UL4 X_5040506 X_PATTERSON DEN,10333280,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM UL5 X_5040548 X_PATTERSON DEN,10333281,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM UL5 X_5040548 X_PATTERSON DEN,10333281,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM UL5 X_5040548 X_PATTERSON DEN,10333281,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM LR4 X_900144 X_PATTERSON DENT,10333282,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM LR4 X_900144 X_PATTERSON DENT,10333282,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM LR4 X_900144 X_PATTERSON DENT,10333282,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM LR3 X_900243 X_PATTERSON DENT,10333283,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM LR3 X_900243 X_PATTERSON DENT,10333283,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM LR3 X_900243 X_PATTERSON DENT,10333283,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CROWN UNITEK SS PRIM LR3 X_900244 X_PATTERSON DENT,10333284,CDM,0270,RC,D2740,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,138.43,,,percent of total billed charges,,,,,,,,,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
CROWN UNITEK SS PRIM LR3 X_900244 X_PATTERSON DENT,10333284,CDM,0270,RC,D2740,HCPCS,05871,APC,,,,outpatient,facility,,,224.00,67.20,224.0,3661.95,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3354.08,,,fee schedule,,,224.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1626.29,,,fee schedule,,,3661.95,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,3305.47,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,1529.33,,,fee schedule,,,1626.29,,,fee schedule,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,224.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1626.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,,,,,,,1594.40,,,fee schedule,,,,,,,,,1610.28,,,fee schedule,,,,,,,,
CROWN UNITEK SS PRIM LR3 X_900244 X_PATTERSON DENT,10333284,CDM,0270,RC,D2740,HCPCS,363,EAPG,,,,outpatient,facility,,,224.00,67.20,224.0,7765.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7765.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6600.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,224.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1969.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2166.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH ANGIO TEMPO 4F 100CM X_452-413H0 X_ALLEGIANCE,10333286,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,243.49,,,percent of total billed charges,,,,,,,,service not payable,192.27,,,percent of total billed charges,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,256.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,256.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH KIT HEMODIALYSIS 24CM,10333287,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1722.00,516.60,731.85,1463.7,,1064.2,,,percent of total billed charges,,,,,,,,service not payable,840.34,,,percent of total billed charges,,,868.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,,,,,,,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,1291.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1463.7,,,percent of total billed charges,,,792.12,,,percent of total billed charges,,,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH KIT HEMO-D 15.5 FR 28CM,10333288,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1722.00,516.60,731.85,1463.7,,1064.2,,,percent of total billed charges,,,,,,,,service not payable,840.34,,,percent of total billed charges,,,868.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,,,,,,,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,1291.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1463.7,,,percent of total billed charges,,,792.12,,,percent of total billed charges,,,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH KIT HEMO-D 15.5 FR 32CM,10333289,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1722.00,516.60,731.85,1463.7,,1064.2,,,percent of total billed charges,,,,,,,,service not payable,840.34,,,percent of total billed charges,,,868.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,,,,,,,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,1291.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1463.7,,,percent of total billed charges,,,792.12,,,percent of total billed charges,,,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER ATTAIN SII DL SML 90MM X_6248V-90S X_MEDT,10333290,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1076.00,322.80,457.30,914.60,,664.97,,,percent of total billed charges,,,,,,,,service not payable,525.09,,,percent of total billed charges,,,542.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,457.30,,,percent of total billed charges,,,,,,,,,807.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,538.0,,,percent of total billed charges,,,,,,,,service not payable,807.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,914.60,,,percent of total billed charges,,,494.96,,,percent of total billed charges,,,,,,,,,699.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,699.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT FLIXENE SNGL 7MMX40CM X_25062 X_GETINGE USA,10333291,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,4197.00,1259.10,1628.44,3567.45,,,,,,,,,,,,,,,,,,,,1628.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1783.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3147.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2098.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3567.45,,,percent of total billed charges,,,1888.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FLIXENE SNGL 7MMX40CM X_25062 X_GETINGE USA,10333291,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,4197.00,1259.10,1783.72,3567.45,,,,,,,,,,,,,service not payable,,,,,,,2116.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1783.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3147.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2098.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3147.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3567.45,,,percent of total billed charges,,,1930.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PTFE STR 6MMX10CM X_25053 X_GETINGE USA,10333292,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PTFE STR 6MMX10CM X_25053 X_GETINGE USA,10333292,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT 11MMX5CM .035IN X_VBH110502A X_W L GOR,10333293,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10792.00,3237.60,4187.30,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4187.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9173.20,,,percent of total billed charges,,,4856.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT 11MMX5CM .035IN X_VBH110502A X_W L GOR,10333293,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10792.00,3237.60,4532.64,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5443.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9173.20,,,percent of total billed charges,,,4964.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT 11MMX10CM .035IN,10333294,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT 11MMX10CM .035IN,10333294,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT 6MMX2.5CM 0.18IN X_VBJR060202A X_W L G,10333295,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11196.00,3358.80,4344.05,9516.60,,5486.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4702.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4344.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4758.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8397.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5598.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9516.60,,,percent of total billed charges,,,5038.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT 6MMX2.5CM 0.18IN X_VBJR060202A X_W L G,10333295,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11196.00,3358.80,4702.32,9516.60,,5486.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4702.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5647.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4758.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8397.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5598.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8397.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9516.60,,,percent of total billed charges,,,5150.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT 6.5MMX15CM .018IN X_VBJR070702A X_W L,10333296,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,12238.00,3671.40,4748.34,10402.30,,5996.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5139.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4748.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5201.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9178.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10402.30,,,percent of total billed charges,,,5507.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT 6.5MMX15CM .018IN X_VBJR070702A X_W L,10333296,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,12238.00,3671.40,5139.96,10402.30,,5996.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5139.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6172.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5201.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9178.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9178.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10402.30,,,percent of total billed charges,,,5629.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT 8MMX2.5CM .014/018 X_VBJR080202A X_W L,10333297,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11196.00,3358.80,4344.05,9516.60,,5486.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4702.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4344.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4758.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8397.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5598.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9516.60,,,percent of total billed charges,,,5038.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT 8MMX2.5CM .014/018 X_VBJR080202A X_W L,10333297,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11196.00,3358.80,4702.32,9516.60,,5486.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4702.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5647.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4758.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8397.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5598.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8397.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9516.60,,,percent of total billed charges,,,5150.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT 8MMX7.5CM .018IN X_VBJR080702A X_W L G,10333298,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,12238.00,3671.40,4748.34,10402.30,,5996.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5139.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4748.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5201.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9178.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10402.30,,,percent of total billed charges,,,5507.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT 8MMX7.5CM .018IN X_VBJR080702A X_W L G,10333298,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,12238.00,3671.40,5139.96,10402.30,,5996.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5139.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6172.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5201.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9178.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9178.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10402.30,,,percent of total billed charges,,,5629.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP VASCULAR ATRAUMATIC 25MM,10333300,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP VASCULAR ATRAUMATIC 25MM,10333300,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP VASCULAR ATRAUMATIC 25MM CVD X_PL548S X_AESCU,10333301,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP VASCULAR ATRAUMATIC 25MM CVD X_PL548S X_AESCU,10333301,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP VASCULAR ATRAUMATIC 45MM STRT X_PL545S X_AESC,10333302,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP VASCULAR ATRAUMATIC 45MM STRT X_PL545S X_AESC,10333302,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP VASC ATRAUMATIC 45MM CVD,10333303,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP VASC ATRAUMATIC 45MM CVD,10333303,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA 4.5X35MM X_481321035 X_STRYKER SPINE,10333779,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA 4.5X35MM X_481321035 X_STRYKER SPINE,10333779,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE VARIAX SLIM STR 5H,10333780,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5017.00,1505.10,1946.60,4264.45,,2458.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2107.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1946.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2132.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4264.45,,,percent of total billed charges,,,2257.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE VARIAX SLIM STR 5H,10333780,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5017.00,1505.10,2107.14,4264.45,,2458.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2107.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2530.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2132.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4264.45,,,percent of total billed charges,,,2307.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Y-PLATE SLIM 3H X_626983 X_STRYKER ORTHOPAEDICS,10333781,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5495.00,1648.50,2132.06,4670.75,,2692.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2307.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2132.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2335.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4121.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2747.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4670.75,,,percent of total billed charges,,,2472.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Y-PLATE SLIM 3H X_626983 X_STRYKER ORTHOPAEDICS,10333781,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5495.00,1648.50,2307.90,4670.75,,2692.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2307.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2771.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2335.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4121.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2747.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4121.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4670.75,,,percent of total billed charges,,,2527.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.7X24MM X_657024 X_STRYKER ORTHOPAE,10333782,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.7X24MM X_657024 X_STRYKER ORTHOPAE,10333782,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.7X26MM X_657026 X_STRYKER ORTHOPAE,10333783,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.7X26MM X_657026 X_STRYKER ORTHOPAE,10333783,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG FT 2.7X28MM X_657028 X_STRYKER ORTHOPAE,10333784,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1370.00,411.00,531.56,1164.5,,,,,,,,,,,,,,,,,,,,531.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.5,,,percent of total billed charges,,,616.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG FT 2.7X28MM X_657028 X_STRYKER ORTHOPAE,10333784,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1370.00,411.00,582.25,1164.5,,,,,,,,,,,,,service not payable,,,,,,,691.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,582.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1027.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,685.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1027.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1164.5,,,percent of total billed charges,,,630.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 4.5 5.5X50MM,10333785,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 4.5 5.5X50MM,10333785,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RADIUS 5.5X30MM X_486615030 X_STRYKER SPINE,10333851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RADIUS 5.5X30MM X_486615030 X_STRYKER SPINE,10333851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FT CAN 6.5X50MM X_7110-6250S X_SMITH NEPHEW,10333852,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT CAN 6.5X50MM X_7110-6250S X_SMITH NEPHEW,10333852,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FT CAN 6.5X85MM X_7110-6285S X_SMITH NEPHEW,10333853,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT CAN 6.5X85MM X_7110-6285S X_SMITH NEPHEW,10333853,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FT CAN 6.5X90MM X_7110-6290S X_SMITH NEPHEW,10333854,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT CAN 6.5X90MM X_7110-6290S X_SMITH NEPHEW,10333854,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
THERAPY UNIT PREVENA PLUS 125,10333855,CDM,0270,RC,A6550,HCPCS,,,,,,outpatient,facility,,,1722.00,516.60,731.85,1463.7,,1064.2,,,percent of total billed charges,,,,,,,,service not payable,840.34,,,percent of total billed charges,,,868.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,,,,,,,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,1291.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1463.7,,,percent of total billed charges,,,792.12,,,percent of total billed charges,,,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1119.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB DYNAGEN DF4 DUAL CHMBR,10333857,CDM,0278,RC,C1721,HCPCS,,,,,,inpatient,facility,,,34655.00,10396.50,13446.14,29456.75,,16980.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14555.1,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,13446.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14728.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25991.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29456.75,,,percent of total billed charges,,,15594.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB DYNAGEN DF4 DUAL CHMBR,10333857,CDM,0278,RC,C1721,HCPCS,,,,,,outpatient,facility,,,34655.00,10396.50,14555.1,29456.75,,16980.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14555.1,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,17479.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14728.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,25991.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,17327.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25991.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,29456.75,,,percent of total billed charges,,,15941.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE 6X12CM,10333858,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,6672.00,2001.60,2588.74,5671.20,,3269.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2802.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2588.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2835.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5004.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5671.20,,,percent of total billed charges,,,3002.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE 6X12CM,10333858,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,6672.00,2001.60,2802.24,5671.20,,3269.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2802.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3365.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2835.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5004.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5004.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5671.20,,,percent of total billed charges,,,3069.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CARTIVA 8MM X_CAR-09-US X_WRIGHT MEDICAL,10333859,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12887.00,3866.10,5000.16,10953.95,,6314.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5412.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5000.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5476.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9665.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6443.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10953.95,,,percent of total billed charges,,,5799.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CARTIVA 8MM X_CAR-09-US X_WRIGHT MEDICAL,10333859,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12887.00,3866.10,5412.54,10953.95,,6314.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5412.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6500.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5476.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9665.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6443.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9665.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10953.95,,,percent of total billed charges,,,5928.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE 5X10CM,10333860,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5208.00,1562.40,2020.70,4426.80,,2551.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2187.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2020.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2213.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3906.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2604.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4426.80,,,percent of total billed charges,,,2343.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE 5X10CM,10333860,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5208.00,1562.40,2187.36,4426.80,,2551.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2187.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2626.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2213.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3906.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2604.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3906.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4426.80,,,percent of total billed charges,,,2395.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROSTHESIS 9MMX5CM,10333861,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10792.00,3237.60,4187.30,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4187.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9173.20,,,percent of total billed charges,,,4856.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROSTHESIS 9MMX5CM,10333861,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10792.00,3237.60,4532.64,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5443.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9173.20,,,percent of total billed charges,,,4964.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROSTHESIS ILIAC,10333862,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROSTHESIS ILIAC,10333862,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN 10X36 RT X_71640636 X_SMITH NEPHEW,10333866,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10900.00,3270.00,4229.20,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4229.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9265.0,,,percent of total billed charges,,,4905.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN 10X36 RT X_71640636 X_SMITH NEPHEW,10333866,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10900.00,3270.00,4578.0,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5497.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9265.0,,,percent of total billed charges,,,5014.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 22F 65CM X_DSF2265 X_W L GORE,10333867,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,3392.00,1017.60,1441.60,2883.20,,2096.26,,,percent of total billed charges,,,,,,,,service not payable,1655.3,,,percent of total billed charges,,,1710.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1441.60,,,percent of total billed charges,,,,,,,,,2544.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1696.0,,,percent of total billed charges,,,,,,,,service not payable,2544.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2883.20,,,percent of total billed charges,,,1560.32,,,percent of total billed charges,,,,,,,,,2204.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2204.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE MAGIC TORQUE DVLR 0.035,10333871,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,422.09,,,percent of total billed charges,,,,,,,,service not payable,333.30,,,percent of total billed charges,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 40MMX60CM,10333872,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL EMBOL DETACH 36MMX60CM,10333873,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,2614.14,,,percent of total billed charges,,,,,,,,service not payable,2064.24,,,percent of total billed charges,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2115.0,,,percent of total billed charges,,,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2749.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER UTERINE HSG 5F EA X_944700 X_CONE INSTRUM,10333874,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,153.00,45.90,65.03,130.05,,94.55,,,percent of total billed charges,,,,,,,,service not payable,74.66,,,percent of total billed charges,,,77.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.03,,,percent of total billed charges,,,,,,,,,114.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,76.5,,,percent of total billed charges,,,,,,,,service not payable,114.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.05,,,percent of total billed charges,,,70.38,,,percent of total billed charges,,,,,,,,,99.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,99.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH HSG 5 FRENCH PACK,10333875,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,146.00,43.80,62.05,124.10,,90.23,,,percent of total billed charges,,,,,,,,service not payable,71.25,,,percent of total billed charges,,,73.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.05,,,percent of total billed charges,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,73.0,,,percent of total billed charges,,,,,,,,service not payable,109.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,124.10,,,percent of total billed charges,,,67.16,,,percent of total billed charges,,,,,,,,,94.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 TRI SZ5 15MM,10333876,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 TRI SZ5 15MM,10333876,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SUPRACONDYLAR 10X200MM X_1826-1020S X_STRYKER,10334139,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6041.00,1812.30,2343.91,5134.85,,2960.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2537.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2343.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2567.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4530.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5134.85,,,percent of total billed charges,,,2718.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SUPRACONDYLAR 10X200MM X_1826-1020S X_STRYKER,10334139,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6041.00,1812.30,2537.22,5134.85,,2960.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2537.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3047.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2567.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4530.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4530.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5134.85,,,percent of total billed charges,,,2778.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATHETER AORTIC 23MM X_EVOLUTPRO-23-US,10334140,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATHETER AORTIC 23MM X_EVOLUTPRO-23-US,10334140,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATHETER AORTIC 26MM X_EVOLUTPRO-26-US,10334141,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATHETER AORTIC 26MM X_EVOLUTPRO-26-US,10334141,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AORTIC VALVE TR-CATH EV-P 29MM,10334142,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AORTIC VALVE TR-CATH EV-P 29MM,10334142,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AORTIC VALVE TRANSCATH 34MM,10334143,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AORTIC VALVE TRANSCATH 34MM,10334143,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATHETER AORTIC 23MM X_EVOLUTR-23-US X_,10334144,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATHETER AORTIC 23MM X_EVOLUTR-23-US X_,10334144,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATHETER AORTIC 26MM X_EVOLUTR-26-US X_,10334145,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATHETER AORTIC 26MM X_EVOLUTR-26-US X_,10334145,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATHETER AORTIC 29MM X_EVOLUTR-29-US X_,10334146,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATHETER AORTIC 29MM X_EVOLUTR-29-US X_,10334146,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE CONFIDA CRV,10334159,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS LUGS SZ1.5 LT,10334160,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS LUGS SZ1.5 LT,10334160,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM TS SZ6 LT,10334161,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20606.00,6181.80,7995.13,17515.10,,10096.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8654.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7995.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8757.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15454.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10303.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17515.10,,,percent of total billed charges,,,9272.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM TS SZ6 LT,10334161,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20606.00,6181.80,8654.52,17515.10,,10096.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8654.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10393.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8757.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15454.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10303.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15454.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17515.10,,,percent of total billed charges,,,9478.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM POST SZ6 10MM X_5544-A-600 X_STRYKER O,10334162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM POST SZ6 10MM X_5544-A-600 X_STRYKER O,10334162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM DIST LT SZ6 10MM X_5541-A-601 X_STRYKE,10334163,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM DIST LT SZ6 10MM X_5541-A-601 X_STRYKE,10334163,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10334584,CDM,0490,RC,32552,CPT,,,,,,outpatient,facility,,,1945.00,583.50,894.70,2912.34,,1945.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,981.06,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10334584,CDM,0490,RC,32552,CPT,05181,APC,,,,outpatient,facility,,,1945.00,583.50,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
SP Exam,10334584,CDM,0490,RC,32552,CPT,68,EAPG,,,,outpatient,facility,,,1945.00,583.50,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10334586,CDM,0490,RC,49422,CPT,,,,,,outpatient,facility,,,3074.00,922.20,1414.04,6509.0,,3074.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1550.53,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,2305.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,2305.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2612.90,,,percent of total billed charges,,,1414.04,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10334586,CDM,0490,RC,49422,CPT,05183,APC,,,,outpatient,facility,,,3074.00,922.20,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
SP Exam,10334586,CDM,0490,RC,49422,CPT,150,EAPG,,,,outpatient,facility,,,3074.00,922.20,1049.65,3313.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3313.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2816.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1049.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1049.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1158.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1273.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10334588,CDM,0320,RC,74470,CPT,,,,,,outpatient,facility,,,1211.00,363.30,58.88,1156.39,,78.91,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,58.88,,,fee schedule,,,610.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,514.67,,,percent of total billed charges,,,,,,,,,908.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,605.5,,,percent of total billed charges,,,,,,,,,908.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1029.35,,,percent of total billed charges,,,557.06,,,percent of total billed charges,,,,,,,,,1156.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10334588,CDM,0320,RC,74470,CPT,05524,APC,,,,outpatient,facility,,,1211.00,363.30,504.34,1207.63,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,1106.10,,,fee schedule,,,504.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",536.32,,,fee schedule,,,1207.63,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,1090.07,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,504.34,,,fee schedule,,,536.32,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,,,,,,,504.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",536.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,525.80,,,fee schedule,,,,,,,,,531.03,,,fee schedule,,,,,,,,
SP Exam,10334588,CDM,0320,RC,74470,CPT,389,EAPG,,,,outpatient,facility,,,1211.00,363.30,172.18,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,287.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANC 6.0X65MM X_608465 X_STRYKER ORTHOPAEDIC,10334660,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6.0X65MM X_608465 X_STRYKER ORTHOPAEDIC,10334660,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6.0X70MM X_608470 X_STRYKER ORTHOPAEDIC,10334661,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6.0X70MM X_608470 X_STRYKER ORTHOPAEDIC,10334661,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6.0X75MM X_608475 X_STRYKER ORTHOPAEDIC,10334662,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6.0X75MM X_608475 X_STRYKER ORTHOPAEDIC,10334662,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5.0X44MM X_661144 X_STRYKER ORTHOPAEDIC,10334663,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5.0X44MM X_661144 X_STRYKER ORTHOPAEDIC,10334663,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG 1MM LAPD LFT X_626901 X_STRYKER ORTHOPA,10334664,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7168.00,2150.40,2781.18,6092.80,,3512.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3010.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2781.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3046.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5376.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3584.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6092.80,,,percent of total billed charges,,,3225.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG 1MM LAPD LFT X_626901 X_STRYKER ORTHOPA,10334664,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7168.00,2150.40,3010.56,6092.80,,3512.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3010.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3615.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3046.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5376.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3584.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5376.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6092.80,,,percent of total billed charges,,,3297.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 3.5X55MM X_661455 X_STRYKER ORTHOPAEDIC,10334665,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,196.00,58.80,76.05,166.60,,,,,,,,,,,,,,,,,,,,76.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.60,,,percent of total billed charges,,,88.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 3.5X55MM X_661455 X_STRYKER ORTHOPAEDIC,10334665,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,196.00,58.80,83.30,166.60,,,,,,,,,,,,,service not payable,,,,,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 3.5X65MM X_661465 X_STRYKER ORTHOPAEDIC,10334666,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,196.00,58.80,76.05,166.60,,,,,,,,,,,,,,,,,,,,76.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.60,,,percent of total billed charges,,,88.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 3.5X65MM X_661465 X_STRYKER ORTHOPAEDIC,10334666,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,196.00,58.80,83.30,166.60,,,,,,,,,,,,,service not payable,,,,,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 3.5X90MM X_661490 X_STRYKER ORTHOPAEDIC,10334667,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,196.00,58.80,76.05,166.60,,,,,,,,,,,,,,,,,,,,76.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.60,,,percent of total billed charges,,,88.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 3.5X90MM X_661490 X_STRYKER ORTHOPAEDIC,10334667,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,196.00,58.80,83.30,166.60,,,,,,,,,,,,,service not payable,,,,,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,83.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,98.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT BONE ANTIBIOTIC REFOBAC,10334668,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT BONE ANTIBIOTIC REFOBAC,10334668,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 6D 8X28X9MM X_48954086 X_STRYKER SPI,10334669,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 6D 8X28X9MM X_48954086 X_STRYKER SPI,10334669,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLCKG HEXALOBE 3.0X60MM X_30-3021 X_ACUMED,10334670,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,427.00,128.10,165.68,362.95,,,,,,,,,,,,,,,,,,,,165.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,192.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLCKG HEXALOBE 3.0X60MM X_30-3021 X_ACUMED,10334670,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,427.00,128.10,181.47,362.95,,,,,,,,,,,,,service not payable,,,,,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,320.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2MM T 6H X_7244-2050N X_SMITH NEPHEW,10334671,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2262.00,678.60,877.66,1922.7,,,,,,,,,,,,,,,,,,,,877.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1696.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1922.7,,,percent of total billed charges,,,1017.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2MM T 6H X_7244-2050N X_SMITH NEPHEW,10334671,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2262.00,678.60,961.35,1922.7,,,,,,,,,,,,,service not payable,,,,,,,1140.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,961.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1696.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1696.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1922.7,,,percent of total billed charges,,,1040.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2X11MM X_7241-2011N X_SMITH NEPHEW,10334672,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2X11MM X_7241-2011N X_SMITH NEPHEW,10334672,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2X10MM X_7241-2010N X_SMITH NEPHEW,10334673,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2X10MM X_7241-2010N X_SMITH NEPHEW,10334673,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROTHESIS EXCLUDER X_HGB161407A X_W L GORE,10334674,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10179.00,3053.70,3949.45,8652.15,,4987.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4275.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3949.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4326.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7634.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5089.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8652.15,,,percent of total billed charges,,,4580.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROTHESIS EXCLUDER X_HGB161407A X_W L GORE,10334674,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10179.00,3053.70,4275.18,8652.15,,4987.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4275.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5134.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4326.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7634.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5089.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7634.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8652.15,,,percent of total billed charges,,,4682.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNTEGRITY MR 4.50MMX12MM X_H7493926012450 X,10334675,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNTEGRITY MR 4.50MMX12MM X_H7493926012450 X,10334675,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 4.50X16MM,10334676,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 4.50X16MM,10334676,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 4.50X20MM,10334677,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 4.50X20MM,10334677,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 4.50X24MM,10334678,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 4.50X24MM,10334678,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 4.50X28MM,10334679,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 4.50X28MM,10334679,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 4.50X32MM,10334680,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 4.50X32MM,10334680,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 5.00X12MM,10334681,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 5.00X12MM,10334681,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 5.00X16MM,10334682,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 5.00X16MM,10334682,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 5.00X20MM,10334683,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 5.00X20MM,10334683,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 5.00X24MM,10334684,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 5.00X24MM,10334684,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNERGY MR 5.00X28MM,10334685,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNERGY MR 5.00X28MM,10334685,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYNTEGRITY MR 5.00MMX32MM X_H7493926032500 X,10334686,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYNTEGRITY MR 5.00MMX32MM X_H7493926032500 X,10334686,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2X12MM X_7241-2012N X_SMITH NEPHEW,10334687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2X12MM X_7241-2012N X_SMITH NEPHEW,10334687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH 6F 7CM RADIAL IDEAL X_PID6F7018NTPD X_MERIT,10334688,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,66.00,19.80,28.05,56.10,,40.79,,,percent of total billed charges,,,,,,,,service not payable,32.21,,,percent of total billed charges,,,33.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,42.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,42.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH METACROSS 7X80MM 135CM,10334689,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,385.63,,,percent of total billed charges,,,,,,,,service not payable,304.51,,,percent of total billed charges,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 1MMX2CM X_APB-1-2-3D-ES X_MEDTR,10334692,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 1MMX2CM X_APB-1-2-3D-ES X_MEDTR,10334692,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 1MMX3CM X_APB-1-3-3D-ES X_MEDTR,10334694,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 1MMX3CM X_APB-1-3-3D-ES X_MEDTR,10334694,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 1MMX4CM X_APB-1-4-3D-ES X_MEDTR,10334695,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 1MMX4CM X_APB-1-4-3D-ES X_MEDTR,10334695,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 1.5MMX2CM X_APB-1.5-2-3D-ES X_M,10334696,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 1.5MMX2CM X_APB-1.5-2-3D-ES X_M,10334696,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 1.5MMX3CM X_APB-1.5-3-3D-ES X_M,10334697,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 1.5MMX3CM X_APB-1.5-3-3D-ES X_M,10334697,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 1.5MMX4CM X_APB-1.5-4-3D-ES X_M,10334698,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 1.5MMX4CM X_APB-1.5-4-3D-ES X_M,10334698,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 2MMX2CM,10334699,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 2MMX2CM,10334699,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 2MMX3CM X_APB-2-3-3D-ES X_MEDTR,10334700,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 2MMX3CM X_APB-2-3-3D-ES X_MEDTR,10334700,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL PRIME BARE 3D 2.5MMX3CM,10334701,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL PRIME BARE 3D 2.5MMX3CM,10334701,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDRO INJECTABLE CEMENT 5CC,10334702,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5270.00,1581.00,2044.76,4479.5,,2582.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2213.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2044.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2239.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3952.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2635.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4479.5,,,percent of total billed charges,,,2371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRO INJECTABLE CEMENT 5CC,10334702,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5270.00,1581.00,2213.40,4479.5,,2582.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2213.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2658.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2239.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3952.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2635.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3952.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4479.5,,,percent of total billed charges,,,2424.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT BONE ANTIBIO REFOBACIN X_1100-34-255 X_ZIMM,10334703,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT BONE ANTIBIO REFOBACIN X_1100-34-255 X_ZIMM,10334703,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH INDIGO 3 LARGE LUMEN,10334709,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,5010.00,1503.00,2129.25,4258.5,,3096.18,,,percent of total billed charges,,,,,,,,service not payable,2444.88,,,percent of total billed charges,,,2527.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2129.25,,,percent of total billed charges,,,,,,,,,3757.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2505.0,,,percent of total billed charges,,,,,,,,service not payable,3757.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4258.5,,,percent of total billed charges,,,2304.60,,,percent of total billed charges,,,,,,,,,3256.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3256.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH INDIGO 5 LARGE LUMEN X_CAT5KIT X_PENUMBRA,10334710,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,5010.00,1503.00,2129.25,4258.5,,3096.18,,,percent of total billed charges,,,,,,,,service not payable,2444.88,,,percent of total billed charges,,,2527.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2129.25,,,percent of total billed charges,,,,,,,,,3757.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2505.0,,,percent of total billed charges,,,,,,,,service not payable,3757.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4258.5,,,percent of total billed charges,,,2304.60,,,percent of total billed charges,,,,,,,,,3256.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3256.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH INDIGO 8 LARGE LUMEN,10334711,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH INDIGO 8 L-LUMEN ASPR,10334712,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,10671.00,3201.30,4535.18,9070.35,,6594.68,,,percent of total billed charges,,,,,,,,service not payable,5207.45,,,percent of total billed charges,,,5382.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4535.18,,,percent of total billed charges,,,,,,,,,8003.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5335.5,,,percent of total billed charges,,,,,,,,service not payable,8003.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9070.35,,,percent of total billed charges,,,4908.66,,,percent of total billed charges,,,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6936.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE SION PTCA 300CM STR 28CM,10334713,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID CRTLC PEGD L60 X_DWE423 X_DWE423 X_TORNIER,10334714,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6290.00,1887.00,2440.52,5346.5,,3082.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2641.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2440.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2673.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4717.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3145.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5346.5,,,percent of total billed charges,,,2830.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID CRTLC PEGD L60 X_DWE423 X_DWE423 X_TORNIER,10334714,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6290.00,1887.00,2641.80,5346.5,,3082.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2641.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3172.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2673.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4717.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3145.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4717.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5346.5,,,percent of total billed charges,,,2893.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM LOW OFFSET 52X19MM X_DWF052 X_TORNIER INC,10334715,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6282.00,1884.60,2437.42,5339.70,,3078.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2638.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2437.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2669.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4711.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3141.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5339.70,,,percent of total billed charges,,,2826.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM LOW OFFSET 52X19MM X_DWF052 X_TORNIER INC,10334715,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6282.00,1884.60,2638.44,5339.70,,3078.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2638.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3168.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2669.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4711.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3141.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4711.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5339.70,,,percent of total billed charges,,,2889.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DX EXPO VENT PIG 6FX125CM,10335350,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,59.00,17.70,25.07,50.15,,36.46,,,percent of total billed charges,,,,,,,,service not payable,28.79,,,percent of total billed charges,,,29.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,44.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,,,,,,service not payable,44.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,50.15,,,percent of total billed charges,,,27.14,,,percent of total billed charges,,,,,,,,,38.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,38.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GEL GLAUCOMA DEVICE XEN,10335353,CDM,0278,RC,L8612,HCPCS,,,,,,inpatient,facility,,,3961.00,1188.30,1536.87,3366.85,,,,,,,,,,,,,,,,,,,,1536.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1683.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2970.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1980.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3366.85,,,percent of total billed charges,,,1782.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GEL GLAUCOMA DEVICE XEN,10335353,CDM,0278,RC,L8612,HCPCS,,,,,,outpatient,facility,,,3961.00,1188.30,1683.42,3366.85,,,,,,,,,,,,,service not payable,,,,,,,1997.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1683.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2970.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1980.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2970.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3366.85,,,percent of total billed charges,,,1822.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT GLENOID CORTILOC LG RT X_DWK405RA25S X_TOR,10335424,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12248.00,3674.40,4752.22,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4752.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10410.80,,,percent of total billed charges,,,5511.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT GLENOID CORTILOC LG RT X_DWK405RA25S X_TOR,10335424,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12248.00,3674.40,5144.16,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6177.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10410.80,,,percent of total billed charges,,,5634.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 2.7X30MM X_657130 X_STRYKER ORTHOPA,10335510,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,743.00,222.90,288.28,631.55,,,,,,,,,,,,,,,,,,,,288.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.55,,,percent of total billed charges,,,334.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 2.7X30MM X_657130 X_STRYKER ORTHOPA,10335510,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,743.00,222.90,315.77,631.55,,,,,,,,,,,,,service not payable,,,,,,,374.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,315.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,557.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,371.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,557.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,631.55,,,percent of total billed charges,,,341.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 8X23X0DEG X_48951080 X_STRYKER SPINE,10335511,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11146.00,3343.80,4324.65,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4324.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.10,,,percent of total billed charges,,,5015.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 8X23X0DEG X_48951080 X_STRYKER SPINE,10335511,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11146.00,3343.80,4681.32,9474.10,,5461.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4681.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5622.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4737.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8359.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5573.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8359.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9474.10,,,percent of total billed charges,,,5127.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 8X56MMX120CM,10335512,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2557.00,767.10,992.12,2173.45,,,,,,,,,,,,,,,,,,,,992.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1086.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1917.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1278.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2173.45,,,percent of total billed charges,,,1150.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 8X56MMX120CM,10335512,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2557.00,767.10,1086.72,2173.45,,,,,,,,,,,,,service not payable,,,,,,,1289.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1086.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1917.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1278.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1917.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2173.45,,,percent of total billed charges,,,1176.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP LK 14H 4.5X265MM,10335513,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2596.00,778.80,1007.25,2206.60,,,,,,,,,,,,,,,,,,,,1007.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1103.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1947.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1298.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2206.60,,,percent of total billed charges,,,1168.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP LK 14H 4.5X265MM,10335513,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2596.00,778.80,1103.3,2206.60,,,,,,,,,,,,,service not payable,,,,,,,1309.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1103.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1947.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1298.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1947.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2206.60,,,percent of total billed charges,,,1194.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL75SH 7F 100CM,10335515,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL1 SH 7FR 100CM,10335518,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ARTERIAL SET 20GX5CM,10335519,CDM,0272,RC,A4344,HCPCS,,,,,,outpatient,facility,,,151.00,45.30,64.17,128.35,,93.32,,,percent of total billed charges,,,,,,,,service not payable,73.69,,,percent of total billed charges,,,76.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,64.17,,,percent of total billed charges,,,,,,,,,113.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,75.5,,,percent of total billed charges,,,,,,,,service not payable,113.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,128.35,,,percent of total billed charges,,,69.46,,,percent of total billed charges,,,,,,,,,98.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,98.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPHERE CNTR GLENOID 42X29MM,10335528,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8395.00,2518.50,3257.26,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3257.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7135.75,,,percent of total billed charges,,,3777.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPHERE CNTR GLENOID 42X29MM,10335528,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8395.00,2518.50,3525.90,7135.75,,4113.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3525.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4234.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3567.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6296.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4197.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6296.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7135.75,,,percent of total billed charges,,,3861.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 2.25X300MM,10335695,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1171.00,351.30,454.35,995.35,,,,,,,,,,,,,,,,,,,,454.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,497.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,878.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,585.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,995.35,,,percent of total billed charges,,,526.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 2.25X300MM,10335695,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1171.00,351.30,497.68,995.35,,,,,,,,,,,,,service not payable,,,,,,,590.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,497.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,878.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,585.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,878.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,995.35,,,percent of total billed charges,,,538.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VARIAX COMPR NARR 7H,10335696,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1881.00,564.30,729.83,1598.85,,,,,,,,,,,,,,,,,,,,729.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1410.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,940.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1598.85,,,percent of total billed charges,,,846.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VARIAX COMPR NARR 7H,10335696,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1881.00,564.30,799.42,1598.85,,,,,,,,,,,,,service not payable,,,,,,,948.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,799.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1410.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,940.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1410.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1598.85,,,percent of total billed charges,,,865.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TRIT SOLIDBACK 52E,10335697,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRIT SOLIDBACK 52E,10335697,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4.0X44MM X_604744 X_STRYKER ORTHOPAEDIC,10335698,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,773.00,231.90,299.92,657.05,,,,,,,,,,,,,,,,,,,,299.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,579.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.05,,,percent of total billed charges,,,347.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4.0X44MM X_604744 X_STRYKER ORTHOPAEDIC,10335698,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,773.00,231.90,328.52,657.05,,,,,,,,,,,,,service not payable,,,,,,,389.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,579.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,386.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,579.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.05,,,percent of total billed charges,,,355.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 6X20X0DEG X_48350060 X_STRYKER,10335699,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 6X20X0DEG X_48350060 X_STRYKER,10335699,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP NONLK HEX 30X4.75MM,10335700,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP NONLK HEX 30X4.75MM,10335700,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM COMP 54X24X58MM,10335701,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4380.00,1314.00,1699.44,3723.0,,,,,,,,,,,,,,,,,,,,1699.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3723.0,,,percent of total billed charges,,,1971.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM COMP 54X24X58MM,10335701,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4380.00,1314.00,1861.5,3723.0,,,,,,,,,,,,,service not payable,,,,,,,2209.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3723.0,,,percent of total billed charges,,,2014.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 12X83MM,10335702,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 12X83MM,10335702,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER CARDIAC DR IS-1,10335703,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,16120.00,4836.00,6254.56,13702.0,,7898.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6770.40,,,percent of total billed charges,,Paid in addition to inpatient services ,6254.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6851.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12090.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8060.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13702.0,,,percent of total billed charges,,,7254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER CARDIAC DR IS-1,10335703,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,16120.00,4836.00,6770.40,13702.0,,7898.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6770.40,,,percent of total billed charges,,Paid in addition to outpatient services ,8130.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6851.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12090.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8060.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12090.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13702.0,,,percent of total billed charges,,,7415.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TBLR LK 3RD SS 10H 131MM,10335705,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TBLR LK 3RD SS 10H 131MM,10335705,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WALKER CAM BOOT TD AIR STD LG X_TDA-LG X_341483,10335873,CDM,0274,RC,L4386,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM BOOT TD AIR STD LG X_TDA-LG X_341483,10335873,CDM,0274,RC,L4386,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,370.64,,,,,,,,161.38,,,fee schedule,,,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,339.48,,,fee schedule,,,130.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",164.61,,,fee schedule,,,370.64,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,334.56,,,fee schedule,,,123.0,,,percent of total billed charges,,,161.38,,,fee schedule,,,130.59,,,fee schedule,,,164.61,,,fee schedule,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,161.38,,,fee schedule,,,123.0,,,percent of total billed charges,,,130.59,,,fee schedule,,,164.61,,,fee schedule,,,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,
Chg Neo FISH Auto (88374-TC),10335930,CDM,0310,RC,88374,CPT,,,,,TC  ,outpatient,facility,,,374.00,112.20,157.86,502.84,,374.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,338.60,,,fee schedule,,,502.84,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.89,,,fee schedule,,,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,366.80,,,fee schedule,,,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,317.90,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Chg Neo FISH Auto (88374-TC),10335930,CDM,0310,RC,88374,CPT,05672,APC,,,TC  ,outpatient,facility,,,374.00,112.20,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Chg Neo FISH Auto (88374-TC),10335930,CDM,0310,RC,88374,CPT,306,EAPG,,,TC  ,outpatient,facility,,,374.00,112.20,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg Neo FISH Manual (88377-TC),10335931,CDM,0310,RC,88377,CPT,,,,,TC  ,outpatient,facility,,,374.00,112.20,157.86,641.75,,374.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,315.04,,,fee schedule,,,641.75,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.84,,,fee schedule,,,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,494.93,,,fee schedule,,,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,317.90,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,179.01,,,fee schedule,,,,,,,,,,,,,,,157.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Chg Neo FISH Manual (88377-TC),10335931,CDM,0310,RC,88377,CPT,05672,APC,,,TC  ,outpatient,facility,,,374.00,112.20,157.63,377.42,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,345.69,,,fee schedule,,,157.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",167.62,,,fee schedule,,,377.42,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,340.68,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,157.63,,,fee schedule,,,167.62,,,fee schedule,,,,,,,,,164.33,,,fee schedule,,,,,,,,,157.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",167.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,,,,,,,164.33,,,fee schedule,,,,,,,,,165.96,,,fee schedule,,,,,,,,
Chg Neo FISH Manual (88377-TC),10335931,CDM,0310,RC,88377,CPT,306,EAPG,,,TC  ,outpatient,facility,,,374.00,112.20,191.39,228.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,194.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,191.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,192.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,211.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg Tissue Culture Neoplastic Disorders addl,10335932,CDM,0311,RC,88237,CPT,,,,,,outpatient,facility,,,99.00,29.70,45.54,299.79,,99.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,97.02,,,fee schedule,,,99.0,,,fee schedule,,,299.79,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,204.93,,,fee schedule,,,99.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",98.96,,,fee schedule,,,223.74,,,fee schedule,,,,,,,,,97.02,,,fee schedule,,,,,,,,,184.94,,,fee schedule,,,201.96,,,fee schedule,,,74.25,,,percent of total billed charges,,,97.02,,,fee schedule,,,99.0,,,fee schedule,,,98.96,,,fee schedule,,,217.5,,,fee schedule,,,97.02,,,fee schedule,,,74.25,,,percent of total billed charges,,,,,,,,,98.96,,,fee schedule,,,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,158.13,,,fee schedule,,,97.02,,,fee schedule,,,,,,,,,139.44,,,fee schedule,,,97.02,,,fee schedule,,,,,,,,,97.02,,,fee schedule,,,,,,,,
Chg Tissue Culture Neoplastic Disorders addl,10335932,CDM,0311,RC,88237,CPT,308,EAPG,,,,outpatient,facility,,,99.00,29.70,99.0,523.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,445.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,99.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,99.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,146.32,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,160.95,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg Tissue Culture Solid Tumor addl,10335933,CDM,0311,RC,88239,CPT,,,,,,outpatient,facility,,,99.00,29.70,45.54,307.65,,99.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,97.02,,,fee schedule,,,99.0,,,fee schedule,,,307.65,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,204.93,,,fee schedule,,,99.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",98.96,,,fee schedule,,,223.74,,,fee schedule,,,,,,,,,97.02,,,fee schedule,,,,,,,,,189.99,,,fee schedule,,,201.96,,,fee schedule,,,74.25,,,percent of total billed charges,,,97.02,,,fee schedule,,,99.0,,,fee schedule,,,98.96,,,fee schedule,,,223.44,,,fee schedule,,,97.02,,,fee schedule,,,74.25,,,percent of total billed charges,,,,,,,,,98.96,,,fee schedule,,,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,162.27,,,fee schedule,,,97.02,,,fee schedule,,,,,,,,,143.09,,,fee schedule,,,97.02,,,fee schedule,,,,,,,,,97.02,,,fee schedule,,,,,,,,
Chg Tissue Culture Solid Tumor addl,10335933,CDM,0311,RC,88239,CPT,308,EAPG,,,,outpatient,facility,,,99.00,29.70,99.0,523.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,445.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,99.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,99.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,146.32,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,160.95,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg Chromosome Analysis 20-25 cells 2 Karyocytes,10335934,CDM,0311,RC,88264,CPT,,,,,,outpatient,facility,,,264.00,79.20,121.44,326.82,,264.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,141.72,,,fee schedule,,,264.0,,,fee schedule,,,301.58,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,299.34,,,fee schedule,,,137.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",144.55,,,fee schedule,,,326.82,,,fee schedule,,,,,,,,,141.72,,,fee schedule,,,,,,,,,186.21,,,fee schedule,,,295.00,,,fee schedule,,,198.0,,,percent of total billed charges,,,141.72,,,fee schedule,,,137.38,,,fee schedule,,,144.55,,,fee schedule,,,218.99,,,fee schedule,,,141.72,,,fee schedule,,,198.0,,,percent of total billed charges,,,,,,,,,144.55,,,fee schedule,,,,,,,,,224.40,,,percent of total billed charges,,,121.44,,,percent of total billed charges,,,,,,,,,159.07,,,fee schedule,,,141.72,,,fee schedule,,,,,,,,,140.27,,,fee schedule,,,141.72,,,fee schedule,,,,,,,,,143.14,,,fee schedule,,,,,,,,
Chg Chromosome Analysis 20-25 cells 2 Karyocytes,10335934,CDM,0311,RC,88264,CPT,386,EAPG,,,,outpatient,facility,,,264.00,79.20,117.18,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10336079,CDM,0360,RC,33990,CPT,,,,,,outpatient,facility,,,7103.00,2130.90,315.44,7856.0,,7103.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,3582.75,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,315.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,5327.25,,,percent of total billed charges,,,,,,,,service not payable,315.44,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,5327.25,,,percent of total billed charges,,,315.44,,,fee schedule,,,,,,,,service not payable,,,,,,,6037.55,,,percent of total billed charges,,,3267.38,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10336079,CDM,0360,RC,33990,CPT,3060,EAPG,,,,outpatient,facility,,,7103.00,2130.90,7103.0,83927.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83927.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,71338.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,57974.96,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,63772.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10336081,CDM,0360,RC,33992,CPT,,,,,,outpatient,facility,,,10928.00,3278.40,195.63,9288.80,,7119.04,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,5512.08,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,8196.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,8196.0,,,percent of total billed charges,,,195.63,,,fee schedule,,,,,,,,service not payable,,,,,,,9288.80,,,percent of total billed charges,,,5026.88,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10336081,CDM,0360,RC,33992,CPT,87,EAPG,,,,outpatient,facility,,,10928.00,3278.40,10511.79,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10336103,CDM,0360,RC,33993,CPT,,,,,,outpatient,facility,,,13113.00,3933.90,158.34,11146.05,,7119.04,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,6614.20,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,158.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,158.34,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,9834.75,,,percent of total billed charges,,,158.34,,,fee schedule,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10336103,CDM,0360,RC,33993,CPT,87,EAPG,,,,outpatient,facility,,,13113.00,3933.90,10511.79,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW LK T8 FT 2.7X30MM,10336117,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.7X30MM,10336117,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FT 2.7X34MM X_656434 X_STRYKER ORTHOPAE,10336118,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FT 2.7X34MM X_656434 X_STRYKER ORTHOPAE,10336118,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL KNEE SZ 4 9MM,10336119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL KNEE SZ 4 9MM,10336119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FLUTED 18X150MM X_5566-S-018 X_STRYKER,10336121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4080.00,1224.00,1583.04,3468.0,,,,,,,,,,,,,,,,,,,,1583.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1734.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3060.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2040.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3468.0,,,percent of total billed charges,,,1836.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FLUTED 18X150MM X_5566-S-018 X_STRYKER,10336121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4080.00,1224.00,1734.0,3468.0,,,,,,,,,,,,,service not payable,,,,,,,2057.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1734.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3060.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2040.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3060.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3468.0,,,percent of total billed charges,,,1876.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM DIST RT SZ6 10MM X_5541-A-602 X_STRYKE,10336123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3722.00,1116.60,1444.14,3163.70,,,,,,,,,,,,,,,,,,,,1444.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3163.70,,,percent of total billed charges,,,1674.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM DIST RT SZ6 10MM X_5541-A-602 X_STRYKE,10336123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3722.00,1116.60,1581.85,3163.70,,,,,,,,,,,,,service not payable,,,,,,,1877.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1581.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2791.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1861.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2791.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3163.70,,,percent of total billed charges,,,1712.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VAS PROPATEN 7MMX40X50CM,10336128,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,5793.00,1737.90,2247.68,4924.05,,2838.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2433.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2247.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2462.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4344.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2896.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4924.05,,,percent of total billed charges,,,2606.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VAS PROPATEN 7MMX40X50CM,10336128,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,5793.00,1737.90,2433.06,4924.05,,2838.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2433.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2921.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2462.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4344.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2896.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4344.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4924.05,,,percent of total billed charges,,,2664.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LP NLCK 4.0X20MM X_AR-8840-20 X_ARTHREX,10336137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LP NLCK 4.0X20MM X_AR-8840-20 X_ARTHREX,10336137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Hypersensitivity Pneumonitis Extended Panel 300156,10336236,CDM,0300,RC,86005,CPT,,,,,59  ,outpatient,facility,,,10.15,3.05,4.67,18.01,,10.15,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.81,,,fee schedule,,,10.15,,,fee schedule,,,16.63,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,16.50,,,fee schedule,,,7.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.97,,,fee schedule,,,18.01,,,fee schedule,,,,,,,,,7.81,,,fee schedule,,,,,,,,,10.12,,,fee schedule,,,16.26,,,fee schedule,,,7.61,,,percent of total billed charges,,,7.81,,,fee schedule,,,7.57,,,fee schedule,,,7.97,,,fee schedule,,,11.90,,,fee schedule,,,7.81,,,fee schedule,,,7.61,,,percent of total billed charges,,,,,,,,,7.97,,,fee schedule,,,,,,,,,8.63,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,8.77,,,fee schedule,,,7.81,,,fee schedule,,,,,,,,,7.73,,,fee schedule,,,7.81,,,fee schedule,,,,,,,,,7.89,,,fee schedule,,,,,,,,
Hypersensitivity Pneumonitis Extended Panel 300156,10336236,CDM,0300,RC,86005,CPT,394,EAPG,,,59  ,outpatient,facility,,,10.15,3.05,10.15,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Hypersens Pneumo-Allergen Specific IgE,10336263,CDM,0300,RC,86003,CPT,,,,,,outpatient,facility,,,10.15,3.05,4.67,11.80,,10.15,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.12,,,fee schedule,,,10.15,,,fee schedule,,,10.88,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,10.81,,,fee schedule,,,4.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.22,,,fee schedule,,,11.80,,,fee schedule,,,,,,,,,5.12,,,fee schedule,,,,,,,,,6.73,,,fee schedule,,,10.65,,,fee schedule,,,7.61,,,percent of total billed charges,,,5.12,,,fee schedule,,,4.96,,,fee schedule,,,5.22,,,fee schedule,,,7.92,,,fee schedule,,,5.12,,,fee schedule,,,7.61,,,percent of total billed charges,,,,,,,,,5.22,,,fee schedule,,,,,,,,,8.63,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,5.74,,,fee schedule,,,5.12,,,fee schedule,,,,,,,,,5.06,,,fee schedule,,,5.12,,,fee schedule,,,,,,,,,5.16,,,fee schedule,,,,,,,,
Hypersens Pneumo-Allergen Specific IgE,10336263,CDM,0300,RC,86003,CPT,394,EAPG,,,,outpatient,facility,,,10.15,3.05,10.15,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Hypersens Pneumo-Aspergillus Ab,10336264,CDM,0300,RC,86606,CPT,,,,,,outpatient,facility,,,10.15,3.05,4.67,31.39,,10.15,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,9.95,,,fee schedule,,,10.15,,,fee schedule,,,31.39,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,21.01,,,fee schedule,,,10.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.15,,,fee schedule,,,22.94,,,fee schedule,,,,,,,,,9.95,,,fee schedule,,,,,,,,,19.38,,,fee schedule,,,20.71,,,fee schedule,,,7.61,,,percent of total billed charges,,,9.95,,,fee schedule,,,10.15,,,fee schedule,,,10.15,,,fee schedule,,,22.79,,,fee schedule,,,9.95,,,fee schedule,,,7.61,,,percent of total billed charges,,,,,,,,,10.15,,,fee schedule,,,,,,,,,8.63,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,16.56,,,fee schedule,,,9.95,,,fee schedule,,,,,,,,,14.60,,,fee schedule,,,9.95,,,fee schedule,,,,,,,,,9.95,,,fee schedule,,,,,,,,
Hypersens Pneumo-Aspergillus Ab,10336264,CDM,0300,RC,86606,CPT,394,EAPG,,,,outpatient,facility,,,10.15,3.05,10.15,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Hypersens Pneumo-Immunodiffusion,10336265,CDM,0300,RC,86331,CPT,,,,,,outpatient,facility,,,10.15,3.05,4.67,24.99,,10.15,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,9.95,,,fee schedule,,,10.15,,,fee schedule,,,24.99,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,21.01,,,fee schedule,,,10.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.15,,,fee schedule,,,22.94,,,fee schedule,,,,,,,,,9.95,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,20.71,,,fee schedule,,,7.61,,,percent of total billed charges,,,9.95,,,fee schedule,,,10.15,,,fee schedule,,,10.15,,,fee schedule,,,18.33,,,fee schedule,,,9.95,,,fee schedule,,,7.61,,,percent of total billed charges,,,,,,,,,10.15,,,fee schedule,,,,,,,,,8.63,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,13.18,,,fee schedule,,,9.95,,,fee schedule,,,,,,,,,11.62,,,fee schedule,,,9.95,,,fee schedule,,,,,,,,,9.95,,,fee schedule,,,,,,,,
Hypersens Pneumo-Immunodiffusion,10336265,CDM,0300,RC,86331,CPT,394,EAPG,,,,outpatient,facility,,,10.15,3.05,10.15,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ALLOGRAFT AMNIOFILL ECM 500.0MG X_AF-0500 X_MIMEDX,10336617,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT AMNIOFILL ECM 500.0MG X_AF-0500 X_MIMEDX,10336617,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT AMNIOFILL ECM 500.0MG X_AF-0500 X_MIMEDX,10336617,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,3443.00,1032.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROFYLE MED STR 4H X_57-05202 X_STRYKER ORTH,10336618,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,981.00,294.30,380.63,833.85,,,,,,,,,,,,,,,,,,,,380.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,416.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,735.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.85,,,percent of total billed charges,,,441.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROFYLE MED STR 4H X_57-05202 X_STRYKER ORTH,10336618,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,981.00,294.30,416.93,833.85,,,,,,,,,,,,,service not payable,,,,,,,494.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,735.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,490.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,735.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,833.85,,,percent of total billed charges,,,451.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TRIT SOLIDBACK 54E,10336619,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRIT SOLIDBACK 54E,10336619,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI 60MM X_48552060 X_STRYKER,10336620,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI 60MM X_48552060 X_STRYKER,10336620,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS AAA CONTRA LEG 16X12MM X_PLC121400,10336621,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15303.00,4590.90,5937.56,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5937.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13007.55,,,percent of total billed charges,,,6886.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS AAA CONTRA LEG 16X12MM X_PLC121400,10336621,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15303.00,4590.90,6427.26,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7718.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13007.55,,,percent of total billed charges,,,7039.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE HUMAN 2X1IN,10336624,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3541.00,1062.30,1373.91,3009.85,,,,,,,,,,,,,,,,,,,,1373.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.85,,,percent of total billed charges,,,1593.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE HUMAN 2X1IN,10336624,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3541.00,1062.30,1504.92,3009.85,,,,,,,,,,,,,service not payable,,,,,,,1786.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3009.85,,,percent of total billed charges,,,1628.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT CONT LEG 12MM 10CM,10336625,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15303.00,4590.90,5937.56,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5937.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13007.55,,,percent of total billed charges,,,6886.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT CONT LEG 12MM 10CM,10336625,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15303.00,4590.90,6427.26,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7718.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13007.55,,,percent of total billed charges,,,7039.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT CONT LEG 23MM 12CM,10336626,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15303.00,4590.90,5937.56,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5937.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13007.55,,,percent of total billed charges,,,6886.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT CONT LEG 23MM 12CM,10336626,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15303.00,4590.90,6427.26,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7718.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13007.55,,,percent of total billed charges,,,7039.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS AAA EXTENDER 23MMX3.3CM X_PLA230300,10336627,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10770.00,3231.00,4178.76,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4178.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9154.5,,,percent of total billed charges,,,4846.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS AAA EXTENDER 23MMX3.3CM X_PLA230300,10336627,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10770.00,3231.00,4523.40,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5432.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9154.5,,,percent of total billed charges,,,4954.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOPROSTHESIS AAA EXTENDER 26MMX3.3CM X_PLA260300,10336628,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10770.00,3231.00,4178.76,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4178.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9154.5,,,percent of total billed charges,,,4846.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOPROSTHESIS AAA EXTENDER 26MMX3.3CM X_PLA260300,10336628,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10770.00,3231.00,4523.40,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5432.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9154.5,,,percent of total billed charges,,,4954.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT LP 28.5MM 3.3CM,10336629,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10770.00,3231.00,4178.76,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4178.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9154.5,,,percent of total billed charges,,,4846.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT LP 28.5MM 3.3CM,10336629,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10770.00,3231.00,4523.40,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5432.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9154.5,,,percent of total billed charges,,,4954.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT EXTEND 36MM 4.5CM,10336630,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10770.00,3231.00,4178.76,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4178.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9154.5,,,percent of total billed charges,,,4846.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT EXTEND 36MM 4.5CM,10336630,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10770.00,3231.00,4523.40,9154.5,,5277.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4523.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5432.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4577.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8077.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8077.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9154.5,,,percent of total billed charges,,,4954.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT EXCLR IPSL 31X14.5,10336631,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24880.00,7464.00,9653.44,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9653.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21148.0,,,percent of total billed charges,,,11196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT EXCLR IPSL 31X14.5,10336631,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24880.00,7464.00,10449.6,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12549.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21148.0,,,percent of total billed charges,,,11444.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 5X80MM X_U3513058 X_BARD,10336632,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 TRI SZ5 9MM,10336634,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 TRI SZ5 9MM,10336634,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE SS STRL 0.035X9IN X_3813-1-090 X_STRYKER,10336636,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,149.00,44.70,63.33,126.65,,92.08,,,percent of total billed charges,,,,,,,,service not payable,72.71,,,percent of total billed charges,,,75.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,63.33,,,percent of total billed charges,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.5,,,percent of total billed charges,,,,,,,,service not payable,111.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,96.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,96.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC OP Ostomy care,10336702,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,262.00,78.60,120.52,222.70,,161.92,,,percent of total billed charges,,,,,,,,,127.86,,,percent of total billed charges,,,132.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,196.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,222.70,,,percent of total billed charges,,,120.52,,,percent of total billed charges,,,,,,,,,170.30,,,percent of total billed charges,,,,,,,,,,,,,,,170.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
WC OP Ostomy care,10336702,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,262.00,78.60,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
WC OP Ostomy care,10336702,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,262.00,78.60,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH SELF MALE 14FR,10336828,CDM,0272,RC,A4349,HCPCS,,,,,,outpatient,facility,,,6.00,1.80,2.55,5.10,,3.71,,,percent of total billed charges,,,,,,,,service not payable,2.93,,,percent of total billed charges,,,3.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3.0,,,percent of total billed charges,,,,,,,,service not payable,4.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5.10,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,,,,,,,3.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOWRAP DS WET X_3102-2004 X_STRYKER,10336829,CDM,0278,RC,Q4150,HCPCS,,,,,,inpatient,facility,,,8114.00,2434.20,3148.23,6896.90,,3975.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3407.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3148.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3448.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6085.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4057.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6896.90,,,percent of total billed charges,,,3651.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOWRAP DS WET X_3102-2004 X_STRYKER,10336829,CDM,0278,RC,Q4150,HCPCS,,,,,,outpatient,facility,,,8114.00,2434.20,3407.88,6896.90,,3975.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3407.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4092.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3448.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6085.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4057.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6085.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6896.90,,,percent of total billed charges,,,3732.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOWRAP DS WET X_3102-2004 X_STRYKER,10336829,CDM,0278,RC,Q4150,HCPCS,455,EAPG,,,,outpatient,facility,,,8114.00,2434.20,72.13,84.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,72.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,82.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPACER VETEBRAL PEEK VBR 10X12X28MM X_62-1012-28 X,10336831,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER VETEBRAL PEEK VBR 10X12X28MM X_62-1012-28 X,10336831,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLYAXIAL 8.5X40MM,10336832,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLYAXIAL 8.5X40MM,10336832,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CTRX HEC 4.5X44MM,10336833,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,262.00,78.60,101.66,222.70,,,,,,,,,,,,,,,,,,,,101.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,196.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.70,,,percent of total billed charges,,,117.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CTRX HEC 4.5X44MM,10336833,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,262.00,78.60,111.35,222.70,,,,,,,,,,,,,service not payable,,,,,,,132.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,111.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,196.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,196.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,222.70,,,percent of total billed charges,,,120.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEM 4H DIS RT 3-5.5X14MM,10336834,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEM 4H DIS RT 3-5.5X14MM,10336834,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ALTRX NEUT 40X62MM,10336835,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ALTRX NEUT 40X62MM,10336835,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK OTW 2.50X12MM,10336837,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK PTCA 5F 2.25X30MM,10336838,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT 6MMX10CM STND WALL X_S0601 X_W L GORE,10336839,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,908.00,272.40,352.30,771.80,,,,,,,,,,,,,,,,,,,,352.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,681.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.80,,,percent of total billed charges,,,408.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT 6MMX10CM STND WALL X_S0601 X_W L GORE,10336839,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,908.00,272.40,385.90,771.80,,,,,,,,,,,,,service not payable,,,,,,,458.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,681.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,454.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,681.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,771.80,,,percent of total billed charges,,,417.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Strep Group A PCR,10337027,CDM,0300,RC,87651,CPT,,,,,,outpatient,facility,,,165.00,49.50,33.34,149.14,,149.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,123.75,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,123.75,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Strep Group A PCR,10337027,CDM,0300,RC,87651,CPT,397,EAPG,,,,outpatient,facility,,,165.00,49.50,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Excision pilonidal cyst or sinus complicated,10337325,CDM,0750,RC,11772,CPT,,,,,,outpatient,facility,,,7461.00,2238.30,3432.06,6408.55,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,3763.33,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,5595.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,5595.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6341.85,,,percent of total billed charges,,,3432.06,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Excision pilonidal cyst or sinus complicated,10337325,CDM,0750,RC,11772,CPT,05073,APC,,,,outpatient,facility,,,7461.00,2238.30,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
END-Excision pilonidal cyst or sinus complicated,10337325,CDM,0750,RC,11772,CPT,11,EAPG,,,,outpatient,facility,,,7461.00,2238.30,2600.83,7500.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7500.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6375.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2600.83,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2600.83,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2600.83,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4167.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4583.72,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Albumin EP,10337362,CDM,0300,RC,84165,CPT,,,,,,outpatient,facility,,,83.00,24.90,10.20,70.55,,45.62,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.53,,,fee schedule,,,34.04,,,fee schedule,,,22.40,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,22.23,,,fee schedule,,,10.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.74,,,fee schedule,,,24.27,,,fee schedule,,,,,,,,,10.53,,,fee schedule,,,,,,,,,13.9,,,fee schedule,,,21.91,,,fee schedule,,,62.25,,,percent of total billed charges,,,10.53,,,fee schedule,,,10.20,,,fee schedule,,,10.74,,,fee schedule,,,16.35,,,fee schedule,,,10.53,,,fee schedule,,,62.25,,,percent of total billed charges,,,,,,,,,10.74,,,fee schedule,,,,,,,,,70.55,,,percent of total billed charges,,,38.18,,,percent of total billed charges,,,,,,,,,11.81,,,fee schedule,,,10.53,,,fee schedule,,,,,,,,,10.42,,,fee schedule,,,10.53,,,fee schedule,,,,,,,,,10.63,,,fee schedule,,,,,,,,
Albumin EP,10337362,CDM,0300,RC,84165,CPT,402,EAPG,,,,outpatient,facility,,,83.00,24.90,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL T2 RECON RT1.5 9X380X125D X_1845-0938S X_STRY,10337447,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5605.00,1681.50,2174.74,4764.25,,2746.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2354.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2174.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2382.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4203.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2802.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4764.25,,,percent of total billed charges,,,2522.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL T2 RECON RT1.5 9X380X125D X_1845-0938S X_STRY,10337447,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5605.00,1681.50,2354.10,4764.25,,2746.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2354.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2827.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2382.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4203.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2802.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4203.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4764.25,,,percent of total billed charges,,,2578.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 8.0X105MM X_611305S X_STRYKER ORTHOP,10337448,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 8.0X105MM X_611305S X_STRYKER ORTHOP,10337448,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 8.0X110MM X_611310S X_STRYKER ORTHOP,10337449,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 8.0X110MM X_611310S X_STRYKER ORTHOP,10337449,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 8.0X115MM X_611315S X_STRYKER ORTHOP,10337450,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 8.0X115MM X_611315S X_STRYKER ORTHOP,10337450,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BROAD 14H 267MM X_71809494 X_SMITH NEPHEW,10337452,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1176.00,352.80,456.29,999.60,,,,,,,,,,,,,,,,,,,,456.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,499.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,882.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,588.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,999.60,,,percent of total billed charges,,,529.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BROAD 14H 267MM X_71809494 X_SMITH NEPHEW,10337452,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1176.00,352.80,499.80,999.60,,,,,,,,,,,,,service not payable,,,,,,,593.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,499.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,882.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,588.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,882.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,999.60,,,percent of total billed charges,,,540.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GLD SLNDR TIB PED 5F 10CM X_51-1050 X_TERUM,10337453,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.13,446.25,,324.45,,,percent of total billed charges,,,,,,,,service not payable,256.20,,,percent of total billed charges,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.13,,,percent of total billed charges,,,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF TI 8X11X34MM,10337454,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF TI 8X11X34MM,10337454,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIROD RELINE 5.5X70MM X_14355090 X_NUVASIVE,10337455,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIROD RELINE 5.5X70MM X_14355090 X_NUVASIVE,10337455,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH SEAMGUARD 60MM,10337458,CDM,0272,RC,C1781,HCPCS,,,,,,outpatient,facility,,,934.00,280.20,396.95,793.90,,577.21,,,percent of total billed charges,,,,,,,,service not payable,455.79,,,percent of total billed charges,,,471.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,396.95,,,percent of total billed charges,,,,,,,,,700.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.0,,,percent of total billed charges,,,,,,,,service not payable,700.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,793.90,,,percent of total billed charges,,,429.64,,,percent of total billed charges,,,,,,,,,607.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,607.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TWIN PASS 7MM DIST 135CM,10337459,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,1452.3,,,percent of total billed charges,,,,,,,,service not payable,1146.8,,,percent of total billed charges,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MIDLINE POWERGLIDE 18G 10,10337460,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH .018 DCB 130CM 5X150MM,10337463,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2438.65,4877.30,,3546.08,,,percent of total billed charges,,,,,,,,service not payable,2800.14,,,percent of total billed charges,,,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2869.0,,,percent of total billed charges,,,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Yeast MALDI ID,10337826,CDM,0300,RC,87106,CPT,,,,,,outpatient,facility,,,62.00,18.60,9.80,52.70,,43.87,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.11,,,fee schedule,,,32.74,,,fee schedule,,,21.52,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,21.36,,,fee schedule,,,9.80,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.31,,,fee schedule,,,23.32,,,fee schedule,,,,,,,,,10.11,,,fee schedule,,,,,,,,,13.48,,,fee schedule,,,21.05,,,fee schedule,,,46.5,,,percent of total billed charges,,,10.11,,,fee schedule,,,9.80,,,fee schedule,,,10.31,,,fee schedule,,,15.86,,,fee schedule,,,10.11,,,fee schedule,,,46.5,,,percent of total billed charges,,,,,,,,,10.31,,,fee schedule,,,,,,,,,52.70,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,,,,,,,11.35,,,fee schedule,,,10.11,,,fee schedule,,,,,,,,,10.01,,,fee schedule,,,10.11,,,fee schedule,,,,,,,,,10.21,,,fee schedule,,,,,,,,
Yeast MALDI ID,10337826,CDM,0300,RC,87106,CPT,396,EAPG,,,,outpatient,facility,,,62.00,18.60,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Mold MALDI ID,10337827,CDM,0300,RC,87107,CPT,,,,,,outpatient,facility,,,62.00,18.60,9.80,52.70,,43.87,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.11,,,fee schedule,,,32.74,,,fee schedule,,,21.52,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,21.36,,,fee schedule,,,9.80,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.31,,,fee schedule,,,23.32,,,fee schedule,,,,,,,,,10.11,,,fee schedule,,,,,,,,,13.48,,,fee schedule,,,21.05,,,fee schedule,,,46.5,,,percent of total billed charges,,,10.11,,,fee schedule,,,9.80,,,fee schedule,,,10.31,,,fee schedule,,,15.86,,,fee schedule,,,10.11,,,fee schedule,,,46.5,,,percent of total billed charges,,,,,,,,,10.31,,,fee schedule,,,,,,,,,52.70,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,,,,,,,11.35,,,fee schedule,,,10.11,,,fee schedule,,,,,,,,,10.01,,,fee schedule,,,10.11,,,fee schedule,,,,,,,,,10.21,,,fee schedule,,,,,,,,
Mold MALDI ID,10337827,CDM,0300,RC,87107,CPT,396,EAPG,,,,outpatient,facility,,,62.00,18.60,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Acid Fast Bacilli MALDI ID,10337828,CDM,0300,RC,87118,CPT,,,,,,outpatient,facility,,,62.00,18.60,13.88,52.70,,29.73,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.32,,,fee schedule,,,22.18,,,fee schedule,,,30.47,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,30.24,,,fee schedule,,,13.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.61,,,fee schedule,,,33.02,,,fee schedule,,,,,,,,,14.32,,,fee schedule,,,,,,,,,18.95,,,fee schedule,,,29.80,,,fee schedule,,,46.5,,,percent of total billed charges,,,14.32,,,fee schedule,,,13.88,,,fee schedule,,,14.61,,,fee schedule,,,22.29,,,fee schedule,,,14.32,,,fee schedule,,,46.5,,,percent of total billed charges,,,,,,,,,14.61,,,fee schedule,,,,,,,,,52.70,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,,,,,,,16.07,,,fee schedule,,,14.32,,,fee schedule,,,,,,,,,14.17,,,fee schedule,,,14.32,,,fee schedule,,,,,,,,,14.46,,,fee schedule,,,,,,,,
Acid Fast Bacilli MALDI ID,10337828,CDM,0300,RC,87118,CPT,396,EAPG,,,,outpatient,facility,,,62.00,18.60,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Anaerobic MALDI ID,10337829,CDM,0300,RC,87076,CPT,,,,,,outpatient,facility,,,80.00,24.00,7.68,68.0,,34.35,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.92,,,fee schedule,,,25.63,,,fee schedule,,,16.85,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,16.73,,,fee schedule,,,7.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.08,,,fee schedule,,,18.26,,,fee schedule,,,,,,,,,7.92,,,fee schedule,,,,,,,,,10.54,,,fee schedule,,,16.48,,,fee schedule,,,60.0,,,percent of total billed charges,,,7.92,,,fee schedule,,,7.68,,,fee schedule,,,8.08,,,fee schedule,,,12.39,,,fee schedule,,,7.92,,,fee schedule,,,60.0,,,percent of total billed charges,,,,,,,,,8.08,,,fee schedule,,,,,,,,,68.0,,,percent of total billed charges,,,36.80,,,percent of total billed charges,,,,,,,,,8.89,,,fee schedule,,,7.92,,,fee schedule,,,,,,,,,7.84,,,fee schedule,,,7.92,,,fee schedule,,,,,,,,,8.0,,,fee schedule,,,,,,,,
Anaerobic MALDI ID,10337829,CDM,0300,RC,87076,CPT,396,EAPG,,,,outpatient,facility,,,80.00,24.00,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW COMP HDLS ST 4X32MM X_658032 X_STRYKER ORTHO,10338269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2831.00,849.30,1098.43,2406.35,,,,,,,,,,,,,,,,,,,,1098.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1203.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2123.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1415.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2406.35,,,percent of total billed charges,,,1273.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP HDLS ST 4X32MM X_658032 X_STRYKER ORTHO,10338269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2831.00,849.30,1203.18,2406.35,,,,,,,,,,,,,service not payable,,,,,,,1427.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1203.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2123.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1415.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2123.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2406.35,,,percent of total billed charges,,,1302.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X18MM,10338270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X18MM,10338270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X20MM,10338271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X20MM,10338271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER HIP ACETABULAR 36X56MM,10338272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER HIP ACETABULAR 36X56MM,10338272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL META-TAN TRIGENT 13X38 X_71640838 X_SMITH NEP,10338274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10900.00,3270.00,4229.20,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4229.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9265.0,,,percent of total billed charges,,,4905.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL META-TAN TRIGENT 13X38 X_71640838 X_SMITH NEP,10338274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10900.00,3270.00,4578.0,9265.0,,5341.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5497.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4632.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8175.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5450.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8175.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9265.0,,,percent of total billed charges,,,5014.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SCREW LAG 95X90 X_71642695 X_SMITH NEPHEW,10338275,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SCREW LAG 95X90 X_71642695 X_SMITH NEPHEW,10338275,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPHINCTERTOME JAGTOM REV RX3.9,10338277,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2356.00,706.80,1001.3,2002.60,,1456.01,,,percent of total billed charges,,,,,,,,service not payable,1149.73,,,percent of total billed charges,,,1188.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.3,,,percent of total billed charges,,,,,,,,,1767.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.0,,,percent of total billed charges,,,,,,,,service not payable,1767.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2002.60,,,percent of total billed charges,,,1083.76,,,percent of total billed charges,,,,,,,,,1531.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1531.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM D7.0,10338280,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM D7.0,10338280,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROCESSOR SOUND BAHA 5 COPPER X_95205 X_COCHLEAR A,10338281,CDM,0274,RC,L8690,HCPCS,,,,,,inpatient,facility,,,11525.00,3457.50,4471.70,9796.25,,5647.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4840.5,,,percent of total billed charges,,Paid in addition to inpatient services ,4471.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4898.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9796.25,,,percent of total billed charges,,,5186.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCESSOR SOUND BAHA 5 COPPER X_95205 X_COCHLEAR A,10338281,CDM,0274,RC,L8690,HCPCS,,,,,,outpatient,facility,,,11525.00,3457.50,4840.5,9796.25,,5647.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4840.5,,,percent of total billed charges,,Paid in addition to outpatient services ,5813.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4898.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9796.25,,,percent of total billed charges,,,5301.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR H CON LAT FS/A RT X_5750 X_JOINT RESTORATION,10338282,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24970.00,7491.00,9688.36,21224.5,,12235.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10487.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9688.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10612.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18727.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12485.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21224.5,,,percent of total billed charges,,,11236.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR H CON LAT FS/A RT X_5750 X_JOINT RESTORATION,10338282,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24970.00,7491.00,10487.4,21224.5,,12235.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10487.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12594.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10612.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18727.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12485.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18727.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21224.5,,,percent of total billed charges,,,11486.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GLIDESCOPE GVL STAT SZ4,10338283,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,118.00,35.40,50.15,100.3,,72.92,,,percent of total billed charges,,,,,,,,service not payable,57.58,,,percent of total billed charges,,,59.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,50.15,,,percent of total billed charges,,,,,,,,,88.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,59.0,,,percent of total billed charges,,,,,,,,service not payable,88.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,100.3,,,percent of total billed charges,,,54.28,,,percent of total billed charges,,,,,,,,,76.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,76.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Mycobacterium Tuberculosis PCR,10340354,CDM,0300,RC,87564,CPT,,,,,,outpatient,facility,,,264.00,79.20,74.47,224.40,,163.15,,,percent of total billed charges,,,75.23,,,fee schedule,,,129.89,,,fee schedule,,,160.11,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,158.91,,,fee schedule,,,,,,,,service not payable,76.73,,,fee schedule,,,173.5,,,fee schedule,,,,,,,,,75.23,,,fee schedule,,,,,,,,,112.2,,,percent of total billed charges,,,156.61,,,fee schedule,,,198.0,,,percent of total billed charges,,,75.23,,,fee schedule,,,,,,,,service not payable,76.73,,,fee schedule,,,132.0,,,percent of total billed charges,,,75.23,,,fee schedule,,,198.0,,,percent of total billed charges,,,,,,,,service not payable,76.73,,,fee schedule,,,,,,,,,224.40,,,percent of total billed charges,,,121.44,,,percent of total billed charges,,,,,,,,,84.45,,,fee schedule,,,75.23,,,fee schedule,,,,,,,,,74.47,,,fee schedule,,,75.23,,,fee schedule,,,,,,,,,75.99,,,fee schedule,,,,,,,,
Mycobacterium Tuberculosis PCR,10340354,CDM,0300,RC,87564,CPT,397,EAPG,,,,outpatient,facility,,,264.00,79.20,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COROENT ANT TLIF 14X14X40 8DEG X_5144408 X_NUVASIV,10340404,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 14X14X40 8DEG X_5144408 X_NUVASIV,10340404,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH WOLVERINE MR 3.5X10MM,10340405,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3324.00,997.20,1412.7,2825.40,,2054.23,,,percent of total billed charges,,,,,,,,service not payable,1622.11,,,percent of total billed charges,,,1676.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,,,,,,,2493.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,2493.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2825.40,,,percent of total billed charges,,,1529.04,,,percent of total billed charges,,,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT PALACOS R X_5036963 X_HERAEUS MEDICAL,10340406,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1064.00,319.20,412.83,904.40,,,,,,,,,,,,,,,,,,,,412.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,798.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,532.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,904.40,,,percent of total billed charges,,,478.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT PALACOS R X_5036963 X_HERAEUS MEDICAL,10340406,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1064.00,319.20,452.20,904.40,,,,,,,,,,,,,service not payable,,,,,,,536.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,452.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,798.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,532.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,798.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,904.40,,,percent of total billed charges,,,489.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLYAXIAL 5.5X55MM,10340407,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLYAXIAL 5.5X55MM,10340407,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHAMBER L12.5 12.5,10340408,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHAMBER L12.5 12.5,10340408,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIATHLON CR X3 TIBIAL,10340821,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIATHLON CR X3 TIBIAL,10340821,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BODY CONE PROX RCLM 24X105MM,10340823,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15959.00,4787.70,6192.09,13565.15,,7819.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6702.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6192.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6782.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11969.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7979.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13565.15,,,percent of total billed charges,,,7181.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BODY CONE PROX RCLM 24X105MM,10340823,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15959.00,4787.70,6702.78,13565.15,,7819.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6702.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8049.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6782.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11969.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7979.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11969.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13565.15,,,percent of total billed charges,,,7341.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE ANCHOR SWVLK BIO X_AR-1662BCC-8 X_ARTHREX I,10340825,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2377.00,713.10,922.28,2020.45,,,,,,,,,,,,,,,,,,,,922.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1010.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1188.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,,1069.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE ANCHOR SWVLK BIO X_AR-1662BCC-8 X_ARTHREX I,10340825,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2377.00,713.10,1010.22,2020.45,,,,,,,,,,,,,service not payable,,,,,,,1198.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1010.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1188.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1782.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,,1093.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2 LEVEL 54MM OZARK X_AA01-42F54V X_K2M,10340827,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2 LEVEL 54MM OZARK X_AA01-42F54V X_K2M,10340827,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.0X14MM OZARK X_8801-14014CA X_K2M,10340828,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.0X14MM OZARK X_8801-14014CA X_K2M,10340828,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM TMT VBR-S 11X14X36.5MM,10340829,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16156.00,4846.80,6268.53,13732.6,,7916.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6785.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6268.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6866.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12117.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8078.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13732.6,,,percent of total billed charges,,,7270.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM TMT VBR-S 11X14X36.5MM,10340829,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16156.00,4846.80,6785.52,13732.6,,7916.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6785.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8149.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6866.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12117.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8078.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12117.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13732.6,,,percent of total billed charges,,,7431.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MINI ACUTRAK 2 22MM X_AT2-M22 X_ACUMED,10340831,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2448.00,734.40,949.82,2080.80,,,,,,,,,,,,,,,,,,,,949.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2080.80,,,percent of total billed charges,,,1101.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MINI ACUTRAK 2 22MM X_AT2-M22 X_ACUMED,10340831,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2448.00,734.40,1040.40,2080.80,,,,,,,,,,,,,service not payable,,,,,,,1234.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2080.80,,,percent of total billed charges,,,1126.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MINI ACUTRAK 2 20MM X_AT2-M20 X_ACUMED,10340832,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2448.00,734.40,949.82,2080.80,,,,,,,,,,,,,,,,,,,,949.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2080.80,,,percent of total billed charges,,,1101.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MINI ACUTRAK 2 20MM X_AT2-M20 X_ACUMED,10340832,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2448.00,734.40,1040.40,2080.80,,,,,,,,,,,,,service not payable,,,,,,,1234.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2080.80,,,percent of total billed charges,,,1126.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP 8H 4.5X159MM X_7182-9488 X_SMITH NEPHEW,10340833,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1091.00,327.30,423.31,927.35,,,,,,,,,,,,,,,,,,,,423.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,463.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,818.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,545.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.35,,,percent of total billed charges,,,490.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP 8H 4.5X159MM X_7182-9488 X_SMITH NEPHEW,10340833,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1091.00,327.30,463.68,927.35,,,,,,,,,,,,,service not payable,,,,,,,550.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,463.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,818.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,545.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,818.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,927.35,,,percent of total billed charges,,,501.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE BIOSYNC ANATOM 20X7.5MM,10340834,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE BIOSYNC ANATOM 20X7.5MM,10340834,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE WHISPER XSUPP H 3X300CM,10340836,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER GUIDE EBU375SH 8F 100CM X_LA8EBU375SH X_M,10340837,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER GUIDE EBU35SH 8F 100CM X_LA8EBU35SH X_MED,10340838,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WALKER CAM TD AIR STD XL,10341131,CDM,0274,RC,L4387,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM TD AIR STD XL,10341131,CDM,0274,RC,L4387,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,370.64,,,,,,,,161.38,,,fee schedule,,,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,339.48,,,fee schedule,,,142.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",164.61,,,fee schedule,,,370.64,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,334.56,,,fee schedule,,,123.0,,,percent of total billed charges,,,161.38,,,fee schedule,,,142.76,,,fee schedule,,,164.61,,,fee schedule,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,161.38,,,fee schedule,,,123.0,,,percent of total billed charges,,,142.76,,,fee schedule,,,164.61,,,fee schedule,,,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,
STAPLE DYNANITE 13WX10L MM,10341132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE DYNANITE 13WX10L MM,10341132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANT CERV ST FIXED 4X12MM,10341133,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANT CERV ST FIXED 4X12MM,10341133,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 2 LVL 38MM,10341134,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 2 LVL 38MM,10341134,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE PROWATER PRCA JTIP 180CM,10341138,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,183.60,367.20,,266.98,,,percent of total billed charges,,,,,,,,service not payable,210.82,,,percent of total billed charges,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,183.60,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,216.0,,,percent of total billed charges,,,,,,,,service not payable,324.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,280.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,280.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL BONE HFN RT 11.5MMX16CM,10341193,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6393.00,1917.90,2480.48,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.05,,,percent of total billed charges,,,2876.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL BONE HFN RT 11.5MMX16CM,10341193,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6393.00,1917.90,2685.06,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3224.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.05,,,percent of total billed charges,,,2940.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM PICO 7 WOUND VAC X_66022007 X_SMITH NEPHEW,10341194,CDM,0272,RC,A6550,HCPCS,,,,,,outpatient,facility,,,1454.00,436.20,617.95,1235.90,,898.57,,,percent of total billed charges,,,,,,,,service not payable,709.55,,,percent of total billed charges,,,733.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,617.95,,,percent of total billed charges,,,,,,,,,1090.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,727.0,,,percent of total billed charges,,,,,,,,service not payable,1090.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1235.90,,,percent of total billed charges,,,668.84,,,percent of total billed charges,,,,,,,,,945.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,945.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD UNIPOLAR 61MM X_126661 X_SMITH NEPHEW,10341195,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1606.00,481.80,623.13,1365.10,,,,,,,,,,,,,,,,,,,,623.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.10,,,percent of total billed charges,,,722.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD UNIPOLAR 61MM X_126661 X_SMITH NEPHEW,10341195,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1606.00,481.80,682.55,1365.10,,,,,,,,,,,,,service not payable,,,,,,,810.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1365.10,,,percent of total billed charges,,,738.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BIOPROSTHESIS 6MMX25CM,10341196,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,4131.00,1239.30,1602.83,3511.35,,,,,,,,,,,,,,,,,,,,1602.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3511.35,,,percent of total billed charges,,,1858.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BIOPROSTHESIS 6MMX25CM,10341196,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,4131.00,1239.30,1755.68,3511.35,,,,,,,,,,,,,service not payable,,,,,,,2083.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3511.35,,,percent of total billed charges,,,1900.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BIOPROSTHESIS 6MMX30CM,10341197,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,3984.00,1195.20,1545.79,3386.40,,,,,,,,,,,,,,,,,,,,1545.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2988.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1992.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3386.40,,,percent of total billed charges,,,1792.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BIOPROSTHESIS 6MMX30CM,10341197,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,3984.00,1195.20,1693.2,3386.40,,,,,,,,,,,,,service not payable,,,,,,,2009.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1693.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2988.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1992.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2988.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3386.40,,,percent of total billed charges,,,1832.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BIOPROSTHESIS 6MMX40CM,10341198,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,5754.00,1726.20,2232.55,4890.90,,2819.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2416.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2232.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2445.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4315.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2877.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4890.90,,,percent of total billed charges,,,2589.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BIOPROSTHESIS 6MMX40CM,10341198,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,5754.00,1726.20,2416.68,4890.90,,2819.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2416.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2902.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2445.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4315.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2877.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4315.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4890.90,,,percent of total billed charges,,,2646.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD BIV QUARTET X_1457Q-86 X_ST JUDE,10341414,CDM,0278,RC,C1900,HCPCS,,,,,,inpatient,facility,,,4377.00,1313.10,1698.28,3720.45,,,,,,,,,,,,,,,,,,,,1698.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1860.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3282.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2188.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3720.45,,,percent of total billed charges,,,1969.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD BIV QUARTET X_1457Q-86 X_ST JUDE,10341414,CDM,0278,RC,C1900,HCPCS,,,,,,outpatient,facility,,,4377.00,1313.10,1860.22,3720.45,,,,,,,,,,,,,service not payable,,,,,,,2207.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1860.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3282.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2188.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3282.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3720.45,,,percent of total billed charges,,,2013.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM DIST SZ 6 LT,10341415,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3544.00,1063.20,1375.07,3012.40,,,,,,,,,,,,,,,,,,,,1375.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3012.40,,,percent of total billed charges,,,1594.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM DIST SZ 6 LT,10341415,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3544.00,1063.20,1506.2,3012.40,,,,,,,,,,,,,service not payable,,,,,,,1787.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3012.40,,,percent of total billed charges,,,1630.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX LP ST 3.5X38MM,10341417,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,333.00,99.90,129.20,283.05,,,,,,,,,,,,,,,,,,,,129.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,249.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.05,,,percent of total billed charges,,,149.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX LP ST 3.5X38MM,10341417,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,333.00,99.90,141.53,283.05,,,,,,,,,,,,,service not payable,,,,,,,167.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,141.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,249.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,166.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,249.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,283.05,,,percent of total billed charges,,,153.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BRACE 2-PC RIGID CUSTOM,10341428,CDM,0274,RC,L0486,HCPCS,,,,,,inpatient,facility,,,4591.00,1377.30,1781.31,3902.35,,,,,,,,,,,,,,,,,,,,1781.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1951.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3443.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3902.35,,,percent of total billed charges,,,2065.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRACE 2-PC RIGID CUSTOM,10341428,CDM,0274,RC,L0486,HCPCS,,,,,,outpatient,facility,,,4591.00,1377.30,1951.18,4800.51,,,,,,,,2090.13,,,fee schedule,,,,,,,,,2315.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,4396.93,,,fee schedule,,,,,,,,service not payable,2131.93,,,fee schedule,,,4800.51,,,fee schedule,,,,,,,,,2090.13,,,fee schedule,,,,,,,,,1951.18,,,percent of total billed charges,,Paid in addition to outpatient services ,4333.20,,,fee schedule,,,3443.25,,,percent of total billed charges,,,2090.13,,,fee schedule,,,,,,,,service not payable,2131.93,,,fee schedule,,,2295.5,,,percent of total billed charges,,Paid in addition to outpatient services ,2090.13,,,fee schedule,,,3443.25,,,percent of total billed charges,,,,,,,,service not payable,2131.93,,,fee schedule,,,,,,,,,3902.35,,,percent of total billed charges,,,2111.86,,,percent of total billed charges,,,,,,,,,,,,,,,2090.13,,,fee schedule,,,,,,,,,,,,,,,2090.13,,,fee schedule,,,,,,,,,2111.03,,,fee schedule,,,,,,,,
SCREW LCKG 3.5X32MM X_PLSL3532 X_STRYKER ORTHOPAED,10341842,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,810.00,243.00,314.28,688.5,,,,,,,,,,,,,,,,,,,,314.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,607.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,405.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,688.5,,,percent of total billed charges,,,364.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X32MM X_PLSL3532 X_STRYKER ORTHOPAED,10341842,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,810.00,243.00,344.25,688.5,,,,,,,,,,,,,service not payable,,,,,,,408.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,344.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,607.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,405.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,607.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,688.5,,,percent of total billed charges,,,372.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.0X28MM X_PLSL3028 X_STRYKER ORTHOPAED,10341843,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,810.00,243.00,314.28,688.5,,,,,,,,,,,,,,,,,,,,314.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,607.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,405.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,688.5,,,percent of total billed charges,,,364.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.0X28MM X_PLSL3028 X_STRYKER ORTHOPAED,10341843,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,810.00,243.00,344.25,688.5,,,,,,,,,,,,,service not payable,,,,,,,408.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,344.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,607.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,405.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,607.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,688.5,,,percent of total billed charges,,,372.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANCH MED LFT X_PLP30171 X_STRYKER ORTHOPAEDI,10341844,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3415.00,1024.50,1325.02,2902.75,,,,,,,,,,,,,,,,,,,,1325.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1451.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2561.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1707.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2902.75,,,percent of total billed charges,,,1536.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANCH MED LFT X_PLP30171 X_STRYKER ORTHOPAEDI,10341844,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3415.00,1024.50,1451.38,2902.75,,,,,,,,,,,,,service not payable,,,,,,,1722.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1451.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2561.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1707.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2561.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2902.75,,,percent of total billed charges,,,1570.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FIXOS HDLS 4X36MM,10341845,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FIXOS HDLS 4X36MM,10341845,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VOYAGER 6.5X50MM X_54850016550 X_MEDTRONIC,10341847,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VOYAGER 6.5X50MM X_54850016550 X_MEDTRONIC,10341847,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SET X_6440530 X_MEDTRONIC,10341848,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SET X_6440530 X_MEDTRONIC,10341848,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD 30MM X_641000030 X_MEDTRONIC,10341849,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD 30MM X_641000030 X_MEDTRONIC,10341849,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ILIAC VES 16F 14MMX10CM,10341850,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24315.00,7294.50,9434.22,20667.75,,11914.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10212.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9434.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10333.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12157.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20667.75,,,percent of total billed charges,,,10941.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ILIAC VES 16F 14MMX10CM,10341850,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24315.00,7294.50,10212.30,20667.75,,11914.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10212.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12264.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10333.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18236.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12157.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18236.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20667.75,,,percent of total billed charges,,,11184.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP NONLK HEX 35X4.75MM,10341851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,355.00,106.50,137.74,301.75,,,,,,,,,,,,,,,,,,,,137.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.75,,,percent of total billed charges,,,159.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP NONLK HEX 35X4.75MM,10341851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,355.00,106.50,150.88,301.75,,,,,,,,,,,,,service not payable,,,,,,,179.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,150.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,266.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,177.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,266.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,301.75,,,percent of total billed charges,,,163.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WALKER CAM TD AIR STD SM,10341852,CDM,0274,RC,L4360,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM TD AIR STD SM,10341852,CDM,0274,RC,L4360,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,370.64,,,,,,,,161.38,,,fee schedule,,,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,339.48,,,fee schedule,,,164.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",164.61,,,fee schedule,,,370.64,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,334.56,,,fee schedule,,,123.0,,,percent of total billed charges,,,161.38,,,fee schedule,,,164.0,,,fee schedule,,,164.61,,,fee schedule,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,161.38,,,fee schedule,,,123.0,,,percent of total billed charges,,,164.0,,,fee schedule,,,164.61,,,fee schedule,,,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,
STENT ASCERTA FIRM 4.8F 22CM,10341853,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,420.00,126.00,162.96,357.0,,,,,,,,,,,,,,,,,,,,162.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ASCERTA FIRM 4.8F 22CM,10341853,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,420.00,126.00,178.5,357.0,,,,,,,,,,,,,service not payable,,,,,,,211.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,315.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,210.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,315.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,357.0,,,percent of total billed charges,,,193.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 8.0X115MM X_611115S X_STRYKER ORTHOP,10341854,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 8.0X115MM X_611115S X_STRYKER ORTHOP,10341854,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ASNIS III 3.2X300 NT STR,10341855,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,587.00,176.10,249.47,498.95,,362.77,,,percent of total billed charges,,,,,,,,service not payable,286.46,,,percent of total billed charges,,,296.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.47,,,percent of total billed charges,,,,,,,,,440.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.5,,,percent of total billed charges,,,,,,,,service not payable,440.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.95,,,percent of total billed charges,,,270.02,,,percent of total billed charges,,,,,,,,,381.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,381.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET SLDBCK 50MM D,10349090,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET SLDBCK 50MM D,10349090,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TRIT SOLIDBACK 60G,10349091,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRIT SOLIDBACK 60G,10349091,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE FIXED 6.5X50MM X_13086550 X_NUVASIVE,10349093,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE FIXED 6.5X50MM X_13086550 X_NUVASIVE,10349093,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE FIXED 7.5X50MM X_13087550 X_NUVASIVE,10349094,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE FIXED 7.5X50MM X_13087550 X_NUVASIVE,10349094,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE FIXED 6.5X45MM X_13086545 X_NUVASIVE,10349095,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE FIXED 6.5X45MM X_13086545 X_NUVASIVE,10349095,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE FIXED 5.5X45MM X_13085545 X_NUVASIVE,10349096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE FIXED 5.5X45MM X_13085545 X_NUVASIVE,10349096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE FIXED 5.5X40MM X_13085540 X_NUVASIVE,10349097,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE FIXED 5.5X40MM X_13085540 X_NUVASIVE,10349097,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE FIXED 5.5X35MM X_13085535 X_NUVASIVE,10349098,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE FIXED 5.5X35MM X_13085535 X_NUVASIVE,10349098,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAP SPINE RELINE LOCKING 6MM,10349099,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAP SPINE RELINE LOCKING 6MM,10349099,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RELINE COCR STRT 6.5X500MM X_15460500 X_NUVASI,10349100,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1071.00,321.30,415.55,910.35,,,,,,,,,,,,,,,,,,,,415.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.35,,,percent of total billed charges,,,481.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RELINE COCR STRT 6.5X500MM X_15460500 X_NUVASI,10349100,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1071.00,321.30,455.18,910.35,,,,,,,,,,,,,service not payable,,,,,,,540.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,455.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,803.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,535.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,803.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,910.35,,,percent of total billed charges,,,492.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT GUIDE PLANNING CUSTOM,10349104,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4876.45,9752.90,,7090.93,,,percent of total billed charges,,,,,,,,service not payable,5599.31,,,percent of total billed charges,,,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,7458.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7458.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRSDRV DRVE 2.5X13.25MM,10349105,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,298.00,89.40,115.62,253.30,,,,,,,,,,,,,,,,,,,,115.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,223.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,149.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.30,,,percent of total billed charges,,,134.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRSDRV DRVE 2.5X13.25MM,10349105,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,298.00,89.40,126.65,253.30,,,,,,,,,,,,,service not payable,,,,,,,150.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,126.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,223.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,149.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,223.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,253.30,,,percent of total billed charges,,,137.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NAT RETRO 11.5MMX24CM,10349106,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7480.00,2244.00,2902.24,6358.0,,3665.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3141.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2902.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3179.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5610.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3740.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6358.0,,,percent of total billed charges,,,3366.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NAT RETRO 11.5MMX24CM,10349106,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7480.00,2244.00,3141.60,6358.0,,3665.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3141.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3772.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3179.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5610.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3740.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5610.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6358.0,,,percent of total billed charges,,,3440.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FIX ANG TI 6X75MM,10349107,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1208.00,362.40,468.70,1026.8,,,,,,,,,,,,,,,,,,,,468.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1026.8,,,percent of total billed charges,,,543.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FIX ANG TI 6X75MM,10349107,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1208.00,362.40,513.40,1026.8,,,,,,,,,,,,,service not payable,,,,,,,609.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,906.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1026.8,,,percent of total billed charges,,,555.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FIX ANG TI 6X50MM,10349108,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1208.00,362.40,468.70,1026.8,,,,,,,,,,,,,,,,,,,,468.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1026.8,,,percent of total billed charges,,,543.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FIX ANG TI 6X50MM,10349108,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1208.00,362.40,513.40,1026.8,,,,,,,,,,,,,service not payable,,,,,,,609.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,513.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,906.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,604.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,906.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1026.8,,,percent of total billed charges,,,555.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER SPACING 1.6MM X_201800 X_SMITH NEPHEW,10349109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,57.00,17.10,22.12,48.45,,,,,,,,,,,,,,,,,,,,22.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.45,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SPACING 1.6MM X_201800 X_SMITH NEPHEW,10349109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,57.00,17.10,24.22,48.45,,,,,,,,,,,,,service not payable,,,,,,,28.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,42.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,28.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,42.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,48.45,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT COCHLEAR MODEL X_CI522 X_COCHLEAR AMERICAS,10349114,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,42836.00,12850.80,16620.37,36410.60,,20989.64,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17991.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16620.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18205.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32127.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21418.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36410.60,,,percent of total billed charges,,,19276.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT COCHLEAR MODEL X_CI522 X_COCHLEAR AMERICAS,10349114,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,42836.00,12850.80,17991.12,36410.60,,20989.64,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17991.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21606.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18205.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32127.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21418.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32127.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36410.60,,,percent of total billed charges,,,19704.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Partial hymenectomy or revision of hymenal ring,10349369,CDM,0450,RC,56700,CPT,,,,,,outpatient,facility,,,7406.00,2221.80,774.0,6295.10,,4576.91,,,percent of total billed charges,,,,,,,,,3614.13,,,percent of total billed charges,,,3735.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5554.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5554.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6295.10,,,percent of total billed charges,,,3406.76,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Partial hymenectomy or revision of hymenal ring,10349369,CDM,0450,RC,56700,CPT,05414,APC,,,,outpatient,facility,,,7406.00,2221.80,1462.31,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,1462.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,1462.31,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,1462.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Partial hymenectomy or revision of hymenal ring,10349369,CDM,0450,RC,56700,CPT,188,EAPG,,,,outpatient,facility,,,7406.00,2221.80,3142.16,6582.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6582.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5594.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3142.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3456.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT TIB CR X3 TRAITH NHPL,10349612,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 TRAITH NHPL,10349612,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SMART MEDIUM LEFT 2.8MM,10349613,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6963.00,2088.90,2701.64,5918.55,,3411.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2924.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2701.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2959.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5222.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3481.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5918.55,,,percent of total billed charges,,,3133.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SMART MEDIUM LEFT 2.8MM,10349613,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6963.00,2088.90,2924.46,5918.55,,3411.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2924.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3512.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2959.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5222.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3481.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5222.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5918.55,,,percent of total billed charges,,,3202.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL COMPONENT LEGION SZ6 LT X_71933643 X_SMITH,10349614,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL COMPONENT LEGION SZ6 LT X_71933643 X_SMITH,10349614,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT IFUSE 7.0X65MM X_7065M-90 X_SI BONE,10349616,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT IFUSE 7.0X65MM X_7065M-90 X_SI BONE,10349616,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD IFUSE TI SACROILIAC 7X35MM,10349617,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD IFUSE TI SACROILIAC 7X35MM,10349617,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT SAC IFUSE 7X50MM,10349618,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT SAC IFUSE 7X50MM,10349618,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT COCHLEAR X_CI622 X_COCHLEAR AMERICAS,10349619,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,42039.00,12611.70,16311.13,35733.15,,20599.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17656.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16311.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17866.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,31529.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21019.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35733.15,,,percent of total billed charges,,,18917.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT COCHLEAR X_CI622 X_COCHLEAR AMERICAS,10349619,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,42039.00,12611.70,17656.38,35733.15,,20599.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17656.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21204.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17866.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,31529.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21019.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,31529.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,35733.15,,,percent of total billed charges,,,19337.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CMPRS FT STD 4.6X42MM,10349620,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CMPRS FT STD 4.6X42MM,10349620,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SUPERCROSS STR 150CM,10349621,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1918.00,575.40,815.15,1630.3,,1185.32,,,percent of total billed charges,,,,,,,,service not payable,935.98,,,percent of total billed charges,,,967.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,815.15,,,percent of total billed charges,,,,,,,,,1438.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,959.0,,,percent of total billed charges,,,,,,,,service not payable,1438.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1630.3,,,percent of total billed charges,,,882.28,,,percent of total billed charges,,,,,,,,,1246.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1246.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 800CC,10349625,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 800CC,10349625,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Lymphocyte Cell Typing-KapLam,10350008,CDM,0300,RC,86356,CPT,,,,,,outpatient,facility,,,66.00,19.80,25.98,66.0,,66.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,26.24,,,fee schedule,,,51.77,,,fee schedule,,,55.85,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,55.43,,,fee schedule,,,,,,,,service not payable,26.76,,,fee schedule,,,60.52,,,fee schedule,,,,,,,,,26.24,,,fee schedule,,,,,,,,,34.54,,,fee schedule,,,54.63,,,fee schedule,,,49.5,,,percent of total billed charges,,,26.24,,,fee schedule,,,,,,,,service not payable,26.76,,,fee schedule,,,40.62,,,fee schedule,,,26.24,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,26.76,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,29.46,,,fee schedule,,,26.24,,,fee schedule,,,,,,,,,25.98,,,fee schedule,,,26.24,,,fee schedule,,,,,,,,,26.51,,,fee schedule,,,,,,,,
Lymphocyte Cell Typing-KapLam,10350008,CDM,0300,RC,86356,CPT,395,EAPG,,,,outpatient,facility,,,66.00,19.80,48.13,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HEAD CERAMIC 36MM BIOLOX,10350037,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10740.00,3222.00,4167.12,9129.0,,5262.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4510.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4167.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4564.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8055.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5370.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9129.0,,,percent of total billed charges,,,4833.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD CERAMIC 36MM BIOLOX,10350037,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10740.00,3222.00,4510.80,9129.0,,5262.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4510.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5417.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4564.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8055.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5370.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8055.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9129.0,,,percent of total billed charges,,,4940.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE HIP FEM STD 0MM,10350038,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE HIP FEM STD 0MM,10350038,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR HIP SZ24 28MM,10350039,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR HIP SZ24 28MM,10350039,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1 LEVEL 24MM OZARK,10350040,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1 LEVEL 24MM OZARK,10350040,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARIABLE 4.0X14MM OZARK,10350041,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARIABLE 4.0X14MM OZARK,10350041,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEM DISTAL 16H X_7180-0016 X_SMITH NEPHEW,10350042,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEM DISTAL 16H X_7180-0016 X_SMITH NEPHEW,10350042,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE JL35SH 6F 100CM,10350043,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT COVERED 6X22MM 120CM,10350044,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,8245.00,2473.50,3199.06,7008.25,,4040.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3462.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3199.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3504.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6183.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4122.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7008.25,,,percent of total billed charges,,,3710.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT COVERED 6X22MM 120CM,10350044,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,8245.00,2473.50,3462.90,7008.25,,4040.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3462.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4158.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3504.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6183.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4122.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6183.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7008.25,,,percent of total billed charges,,,3792.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SMOOTH 3.5X28MM X_48556328 X_STRYKER,10350045,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SMOOTH 3.5X28MM X_48556328 X_STRYKER,10350045,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY 3.5X30MM X_48552330 X_STRYKER,10350046,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY 3.5X30MM X_48552330 X_STRYKER,10350046,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE TIB ATTUNE MD LG 29MM,10350047,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12994.00,3898.20,5041.67,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5041.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11044.9,,,percent of total billed charges,,,5847.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE TIB ATTUNE MD LG 29MM,10350047,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12994.00,3898.20,5457.48,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6554.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11044.9,,,percent of total billed charges,,,5977.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB REV ROTATING CEM SZ3,10350049,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17663.00,5298.90,6853.24,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6853.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15013.55,,,percent of total billed charges,,,7948.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB REV ROTATING CEM SZ3,10350049,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17663.00,5298.90,7418.46,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8909.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15013.55,,,percent of total billed charges,,,8124.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ3 16MM X_1516-50-316 X_DEPUY,10350051,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ3 16MM X_1516-50-316 X_DEPUY,10350051,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ9 8MM X_1516-20-908 X_DEPUY,10350053,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ9 8MM X_1516-20-908 X_DEPUY,10350053,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ9 RT X_1504-00-209 X_DEPUY,10350055,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ9 RT X_1504-00-209 X_DEPUY,10350055,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SZ7 RT X_74022117 X_SMITH NEPHEW,10350058,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SZ7 RT X_74022117 X_SMITH NEPHEW,10350058,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART BCS XPLE S77-8 RT,10350059,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS XPLE S77-8 RT,10350059,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW C-FIX COMP 3.5X16MM X_CS16A X_STRYKER ORTHOP,10350062,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1487.00,446.10,576.96,1263.95,,,,,,,,,,,,,,,,,,,,576.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1115.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,743.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.95,,,percent of total billed charges,,,669.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW C-FIX COMP 3.5X16MM X_CS16A X_STRYKER ORTHOP,10350062,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1487.00,446.10,631.98,1263.95,,,,,,,,,,,,,service not payable,,,,,,,750.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,631.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1115.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,743.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1115.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1263.95,,,percent of total billed charges,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT COCHLEAR NPC CI622,10350067,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,42837.00,12851.10,16620.76,36411.45,,20990.13,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17991.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16620.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18205.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32127.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36411.45,,,percent of total billed charges,,,19276.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT COCHLEAR NPC CI622,10350067,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,42837.00,12851.10,17991.54,36411.45,,20990.13,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17991.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21606.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18205.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32127.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21418.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32127.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36411.45,,,percent of total billed charges,,,19705.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD SOLUTIONS ARH 24MM RT X_5001-0224R-S X_ACUMED,10350068,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8445.00,2533.50,3276.66,7178.25,,4138.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3546.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3276.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3589.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6333.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4222.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7178.25,,,percent of total billed charges,,,3800.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD SOLUTIONS ARH 24MM RT X_5001-0224R-S X_ACUMED,10350068,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8445.00,2533.50,3546.90,7178.25,,4138.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3546.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4259.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3589.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6333.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4222.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6333.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7178.25,,,percent of total billed charges,,,3884.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 5.25D 17.0,10350069,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 5.25D 17.0,10350069,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MRI Exam,10350334,CDM,0611,RC,76498,CPT,,,,,,outpatient,facility,,,3558.00,1067.40,190.48,3024.30,,700.70,,FormulaCPE:  {Units in Service Type} * 700.70 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 700.70 End FormulaCPE Paid in addition to outpatient services,,,,,,,550.0,,FormulaCPE:  {Units in Service Type} * 550.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 550.00 End FormulaCPE Paid in addition to outpatient services,988.43,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",other,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.0,,,per diem,,,,,,,,,2668.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1831.0,,,per diem,,,,,,,,,2668.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3024.30,,,percent of total billed charges,,,1636.68,,,percent of total billed charges,,,,,,,,,190.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MRI Exam,10350334,CDM,0611,RC,76498,CPT,05521,APC,,,,outpatient,facility,,,3558.00,1067.40,80.99,193.93,,,,,,,,84.44,,,fee schedule,,,,,,,,,,,,,,,177.63,,,fee schedule,,,80.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",86.13,,,fee schedule,,,193.93,,,fee schedule,,,,,,,,,84.44,,,fee schedule,,,,,,,,,,,,,,,175.05,,,fee schedule,,,,,,,,,84.44,,,fee schedule,,,80.99,,,fee schedule,,,86.13,,,fee schedule,,,,,,,,,84.44,,,fee schedule,,,,,,,,,80.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",86.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.44,,,fee schedule,,,,,,,,,,,,,,,84.44,,,fee schedule,,,,,,,,,85.28,,,fee schedule,,,,,,,,
MRI Exam,10350334,CDM,0611,RC,76498,CPT,293,EAPG,,,,outpatient,facility,,,3558.00,1067.40,351.02,981.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,981.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,834.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,351.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,351.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,597.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,657.45,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MRI Exam,10350336,CDM,0611,RC,76498,CPT,,,,,,outpatient,facility,,,2913.00,873.90,190.48,2476.05,,700.70,,FormulaCPE:  {Units in Service Type} * 700.70 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 700.70 End FormulaCPE Paid in addition to outpatient services,,,,,,,550.0,,FormulaCPE:  {Units in Service Type} * 550.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 550.00 End FormulaCPE Paid in addition to outpatient services,988.43,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",other,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.0,,,per diem,,,,,,,,,2184.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1831.0,,,per diem,,,,,,,,,2184.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2476.05,,,percent of total billed charges,,,1339.98,,,percent of total billed charges,,,,,,,,,190.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MRI Exam,10350336,CDM,0611,RC,76498,CPT,05521,APC,,,,outpatient,facility,,,2913.00,873.90,80.99,193.93,,,,,,,,84.44,,,fee schedule,,,,,,,,,,,,,,,177.63,,,fee schedule,,,80.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",86.13,,,fee schedule,,,193.93,,,fee schedule,,,,,,,,,84.44,,,fee schedule,,,,,,,,,,,,,,,175.05,,,fee schedule,,,,,,,,,84.44,,,fee schedule,,,80.99,,,fee schedule,,,86.13,,,fee schedule,,,,,,,,,84.44,,,fee schedule,,,,,,,,,80.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",86.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.44,,,fee schedule,,,,,,,,,,,,,,,84.44,,,fee schedule,,,,,,,,,85.28,,,fee schedule,,,,,,,,
MRI Exam,10350336,CDM,0611,RC,76498,CPT,293,EAPG,,,,outpatient,facility,,,2913.00,873.90,351.02,981.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,981.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,834.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,351.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,351.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,597.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,657.45,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MRI Exam,10350339,CDM,0614,RC,72197,CPT,,,,,,outpatient,facility,,,3229.00,968.70,550.0,2744.65,,700.70,,,fee schedule,,Paid in addition to outpatient services ,,,,,,,550.0,,,fee schedule,,Paid in addition to outpatient services ,988.43,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",other,,"FormulaCPE:  {Units in Service Type} * 1,019.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.0,,,per diem,,,,,,,,,2421.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1831.0,,,per diem,,,,,,,,,2421.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2744.65,,,percent of total billed charges,,,1485.34,,,percent of total billed charges,,,,,,,,,806.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MRI Exam,10350339,CDM,0614,RC,72197,CPT,05572,APC,,,,outpatient,facility,,,3229.00,968.70,328.5,786.57,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,720.44,,,fee schedule,,,328.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",349.32,,,fee schedule,,,786.57,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,710.0,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,328.5,,,fee schedule,,,349.32,,,fee schedule,,,,,,,,,342.47,,,fee schedule,,,,,,,,,328.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",349.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.47,,,fee schedule,,,,,,,,,,,,,,,342.47,,,fee schedule,,,,,,,,,345.88,,,fee schedule,,,,,,,,
MRI Exam,10350339,CDM,0614,RC,72197,CPT,295,EAPG,,,,outpatient,facility,,,3229.00,968.70,592.21,1332.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1132.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.21,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,592.21,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,592.21,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,823.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,905.70,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PSA Ultrasensitive - Post Prostatectomy,10350399,CDM,0300,RC,84153,CPT,,,,,,outpatient,facility,,,76.00,22.80,17.47,76.0,,76.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,18.02,,,fee schedule,,,58.32,,,fee schedule,,,38.35,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,38.07,,,fee schedule,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18.38,,,fee schedule,,,41.56,,,fee schedule,,,,,,,,,18.02,,,fee schedule,,,,,,,,,23.58,,,fee schedule,,,37.52,,,fee schedule,,,57.0,,,percent of total billed charges,,,18.02,,,fee schedule,,,17.47,,,fee schedule,,,18.38,,,fee schedule,,,27.74,,,fee schedule,,,18.02,,,fee schedule,,,57.0,,,percent of total billed charges,,,,,,,,,18.38,,,fee schedule,,,,,,,,,64.60,,,percent of total billed charges,,,34.96,,,percent of total billed charges,,,,,,,,,20.23,,,fee schedule,,,18.02,,,fee schedule,,,,,,,,,17.84,,,fee schedule,,,18.02,,,fee schedule,,,,,,,,,18.20,,,fee schedule,,,,,,,,
PSA Ultrasensitive - Post Prostatectomy,10350399,CDM,0300,RC,84153,CPT,400,EAPG,,,,outpatient,facility,,,76.00,22.80,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CONNECTOR RAIL LP ADJ LG,10350450,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR RAIL LP ADJ LG,10350450,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB TRI CR X3 SZ 7 9MM,10350451,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB TRI CR X3 SZ 7 9MM,10350451,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 3DMAX RT 4X6IN,10350452,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,776.00,232.80,301.09,659.60,,,,,,,,,,,,,,,,,,,,301.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,329.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,388.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.60,,,percent of total billed charges,,,349.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 3DMAX RT 4X6IN,10350452,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,776.00,232.80,329.80,659.60,,,,,,,,,,,,,service not payable,,,,,,,391.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,329.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,582.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,388.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,582.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,659.60,,,percent of total billed charges,,,356.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL LONG R15 RT 13X400MM 125D,10350453,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL LONG R15 RT 13X400MM 125D,10350453,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE GLENOID 29MM AEQUALI,10350454,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4741.00,1422.30,1839.51,4029.85,,,,,,,,,,,,,,,,,,,,1839.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3555.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2370.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4029.85,,,percent of total billed charges,,,2133.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE GLENOID 29MM AEQUALI,10350454,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4741.00,1422.30,2014.92,4029.85,,,,,,,,,,,,,service not payable,,,,,,,2391.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2014.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3555.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2370.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3555.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4029.85,,,percent of total billed charges,,,2180.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH PHASIX ST RECT 7X10CM,10350456,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4142.00,1242.60,1607.10,3520.70,,,,,,,,,,,,,,,,,,,,1607.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1760.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3106.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2071.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3520.70,,,percent of total billed charges,,,1863.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH PHASIX ST RECT 7X10CM,10350456,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4142.00,1242.60,1760.35,3520.70,,,,,,,,,,,,,service not payable,,,,,,,2089.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1760.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3106.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2071.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3106.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3520.70,,,percent of total billed charges,,,1905.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD 35MM X_641000035 X_MEDTRONIC USA INC,10350458,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD 35MM X_641000035 X_MEDTRONIC USA INC,10350458,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VOYAGER 6.5X45MM X_54850016545 X_MEDTRONIC U,10350459,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VOYAGER 6.5X45MM X_54850016545 X_MEDTRONIC U,10350459,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DEUTSCH GASTROSTOMY 16F X_G01425 X_COOK MEDIC,10350460,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,229.90,,,percent of total billed charges,,,,,,,,service not payable,181.54,,,percent of total billed charges,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,241.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,241.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER SHEATH 9F 13X45CM X_CLS-1009 X_MERIT ME,10350461,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,139.40,,101.35,,,percent of total billed charges,,,,,,,,service not payable,80.03,,,percent of total billed charges,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.70,,,percent of total billed charges,,,,,,,,,123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.0,,,percent of total billed charges,,,,,,,,service not payable,123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,106.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,106.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST CPG GEL HP 545ML,10350463,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST CPG GEL HP 545ML,10350463,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST CPG GEL HP 610ML,10350464,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST CPG GEL HP 610ML,10350464,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST CONTOUR PRO 680ML,10350465,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST CONTOUR PRO 680ML,10350465,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER RECTUM SPACEOAR 10ML,10350468,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9721.00,2916.30,3771.75,8262.85,,4763.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4082.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3771.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4131.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4860.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8262.85,,,percent of total billed charges,,,4374.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER RECTUM SPACEOAR 10ML,10350468,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9721.00,2916.30,4082.82,8262.85,,4763.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4082.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4903.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4131.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7290.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4860.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7290.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8262.85,,,percent of total billed charges,,,4471.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.3X9MM 1_Stryker Corporation_663809,10351130,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.3X9MM 1_Stryker Corporation_663809,10351130,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.3X10MM_Stryker Corporation_663810,10351131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.3X10MM_Stryker Corporation_663810,10351131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.3X11MM X_663811 X_STRYKER ORTHOPAEDIC,10351132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.3X11MM X_663811 X_STRYKER ORTHOPAEDIC,10351132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.3 X 14MM,10351133,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.3 X 14MM,10351133,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.3X16MM X_663816 X_STRYKER ORTHOPAEDIC,10351134,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.3X16MM X_663816 X_STRYKER ORTHOPAEDIC,10351134,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LOCK 2.7X12MM,10351135,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LOCK 2.7X12MM,10351135,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X16MM X_LCBS2.7-16 X_TRI-MED INC,10351136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X16MM X_LCBS2.7-16 X_TRI-MED INC,10351136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X18MM X_LCBS2.7-18 X_TRI-MED INC,10351137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X18MM X_LCBS2.7-18 X_TRI-MED INC,10351137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIBIA LCKG 5H 72MM RT X_7282-0305 X_SMITH NE,10351138,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2330.00,699.00,904.04,1980.5,,,,,,,,,,,,,,,,,,,,904.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,990.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1747.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.5,,,percent of total billed charges,,,1048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIBIA LCKG 5H 72MM RT X_7282-0305 X_SMITH NE,10351138,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2330.00,699.00,990.25,1980.5,,,,,,,,,,,,,service not payable,,,,,,,1175.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,990.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1747.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1747.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1980.5,,,percent of total billed charges,,,1071.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM GLOBAL UNITE REV 8X177MM,10351139,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10053.00,3015.90,3900.56,8545.05,,4925.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4222.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3900.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4272.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7539.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5026.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8545.05,,,percent of total billed charges,,,4523.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM GLOBAL UNITE REV 8X177MM,10351139,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10053.00,3015.90,4222.26,8545.05,,4925.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4222.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5070.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4272.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7539.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5026.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7539.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8545.05,,,percent of total billed charges,,,4624.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST GEL HP 620CC,10351141,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST GEL HP 620CC,10351141,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST GEL HP 545CC,10351142,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST GEL HP 545CC,10351142,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST GEL HP 610CC,10351143,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST GEL HP 610CC,10351143,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST GEL HP 680CC,10351144,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST GEL HP 680CC,10351144,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 3X5CM _EC-5350 X_MIMEDX,10351145,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,10228.00,3068.40,3968.46,8693.80,,5011.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4295.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3968.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4346.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7671.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8693.80,,,percent of total billed charges,,,4602.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 3X5CM _EC-5350 X_MIMEDX,10351145,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,10228.00,3068.40,4295.76,8693.80,,5011.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4295.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5159.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4346.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7671.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7671.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8693.80,,,percent of total billed charges,,,4704.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE COMP 7.0X80MM,10351148,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3639.00,1091.70,1411.93,3093.15,,,,,,,,,,,,,,,,,,,,1411.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1546.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2729.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3093.15,,,percent of total billed charges,,,1637.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE COMP 7.0X80MM,10351148,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3639.00,1091.70,1546.58,3093.15,,,,,,,,,,,,,service not payable,,,,,,,1835.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1546.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2729.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2729.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3093.15,,,percent of total billed charges,,,1673.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE 25X22X22,10351149,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6479.00,1943.70,2513.85,5507.15,,3174.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2721.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2513.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2753.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4859.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3239.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5507.15,,,percent of total billed charges,,,2915.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE 25X22X22,10351149,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6479.00,1943.70,2721.18,5507.15,,3174.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2721.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3268.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2753.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4859.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3239.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4859.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5507.15,,,percent of total billed charges,,,2980.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VASC PROPATEN 8MMX40CM,10351343,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3393.00,1017.90,1316.48,2884.05,,,,,,,,,,,,,,,,,,,,1316.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2884.05,,,percent of total billed charges,,,1526.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VASC PROPATEN 8MMX40CM,10351343,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3393.00,1017.90,1442.02,2884.05,,,,,,,,,,,,,service not payable,,,,,,,1711.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2544.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2884.05,,,percent of total billed charges,,,1560.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE GEM DIST RAD STND RT 7H X_GMN-RTS-7HL X_SKEL,10351344,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE GEM DIST RAD STND RT 7H X_GMN-RTS-7HL X_SKEL,10351344,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROT FRAG DIST ULNA X_PRT-FSP-DU X_SKELETAL,10351345,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROT FRAG DIST ULNA X_PRT-FSP-DU X_SKELETAL,10351345,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG SMTH 2.0X12MM X_SPLS-20120-TS X_SKELETAL,10351346,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG SMTH 2.0X12MM X_SPLS-20120-TS X_SKELETAL,10351346,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG HCOMP 2.7X16MM X_HCLP-27160-TS X_SKELETAL,10351347,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG HCOMP 2.7X16MM X_HCLP-27160-TS X_SKELETAL,10351347,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG HCOMP 2.7X18MM X_HCLP-27180-TS X_SKELETAL,10351348,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG HCOMP 2.7X18MM X_HCLP-27180-TS X_SKELETAL,10351348,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG THRD 2.3X10MM X_TPLS-23100-TS X_SKELETAL,10351349,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG THRD 2.3X10MM X_TPLS-23100-TS X_SKELETAL,10351349,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LCKG THRD 2.3X12MM X_TPLS-23120-TS X_SKELETAL,10351350,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LCKG THRD 2.3X12MM X_TPLS-23120-TS X_SKELETAL,10351350,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG THRD NON-LK 2.7X14MM X_TPNL-27140-TS X_SKELETA,10351351,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG THRD NON-LK 2.7X14MM X_TPNL-27140-TS X_SKELETA,10351351,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LK 10X3.5MM,10351352,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LK 10X3.5MM,10351352,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LK 11X3.5MM,10351353,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LK 11X3.5MM,10351353,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LK 14X3.5MM,10351354,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LK 14X3.5MM,10351354,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DISTAL RAD 3H RT NRW,10351355,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DISTAL RAD 3H RT NRW,10351355,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LOCKING SMOOTH 16X2.0MM,10351356,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,624.00,187.20,242.11,530.40,,,,,,,,,,,,,,,,,,,,242.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.40,,,percent of total billed charges,,,280.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LOCKING SMOOTH 16X2.0MM,10351356,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,,,,,,,,,,,,service not payable,,,,,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Screw Cannulated TI LP 3X20MM X_Arthrex X_AR-8730-,10351358,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Screw Cannulated TI LP 3X20MM X_Arthrex X_AR-8730-,10351358,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER PRIMO MRI DVC ICD VR,10351359,CDM,0275,RC,C1722,HCPCS,,,,,,inpatient,facility,,,36117.00,10835.10,14013.40,30699.45,,17697.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15169.14,,,percent of total billed charges,,Paid in addition to inpatient services ,14013.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15349.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27087.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18058.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30699.45,,,percent of total billed charges,,,16252.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER PRIMO MRI DVC ICD VR,10351359,CDM,0275,RC,C1722,HCPCS,,,,,,outpatient,facility,,,36117.00,10835.10,15169.14,30699.45,,17697.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15169.14,,,percent of total billed charges,,Paid in addition to outpatient services ,18217.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15349.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27087.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18058.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27087.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,30699.45,,,percent of total billed charges,,,16613.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER SHEATH VASC 8F 13X19.5CM X_SS8 X_ABBOTT,10351361,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,232.00,69.60,98.60,197.20,,143.38,,,percent of total billed charges,,,,,,,,service not payable,113.22,,,percent of total billed charges,,,117.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,98.60,,,percent of total billed charges,,,,,,,,,174.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,116.0,,,percent of total billed charges,,,,,,,,service not payable,174.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,197.20,,,percent of total billed charges,,,106.72,,,percent of total billed charges,,,,,,,,,150.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,150.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 TRAITH 9MM,10351365,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 TRAITH 9MM,10351365,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON NCB CABLE,10351619,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,906.00,271.80,351.53,770.10,,,,,,,,,,,,,,,,,,,,351.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,679.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.10,,,percent of total billed charges,,,407.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUTTON NCB CABLE,10351619,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,906.00,271.80,385.05,770.10,,,,,,,,,,,,,service not payable,,,,,,,456.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,385.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,679.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,453.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,679.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,770.10,,,percent of total billed charges,,,416.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL SHAFT FF ALLOGRAFT 25CM X_AT648FF X_ALAMO T,10351620,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL SHAFT FF ALLOGRAFT 25CM X_AT648FF X_ALAMO T,10351620,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP CANN FT 60X5MM LG,10351623,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP CANN FT 60X5MM LG,10351623,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKG STR 7H X_AR-8943C-07 X_ARTHREX INC,10351625,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG STR 7H X_AR-8943C-07 X_ARTHREX INC,10351625,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORT 2.7X48MM X_AR-8827-48 X_ARTHREX INC,10351626,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORT 2.7X48MM X_AR-8827-48 X_ARTHREX INC,10351626,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT 3.5X46MM X_AR-8835-46 X_ARTHREX INC,10351627,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,437.00,131.10,169.56,371.45,,,,,,,,,,,,,,,,,,,,169.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,196.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT 3.5X46MM X_AR-8835-46 X_ARTHREX INC,10351627,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,,,,,,,,,,,,service not payable,,,,,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORT 2.7X52MM X_AR-8827-52 X_ARTHREX INC,10351628,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORT 2.7X52MM X_AR-8827-52 X_ARTHREX INC,10351628,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM COMP 54X27X55MM,10351629,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4380.00,1314.00,1699.44,3723.0,,,,,,,,,,,,,,,,,,,,1699.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3723.0,,,percent of total billed charges,,,1971.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM COMP 54X27X55MM,10351629,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4380.00,1314.00,1861.5,3723.0,,,,,,,,,,,,,service not payable,,,,,,,2209.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3723.0,,,percent of total billed charges,,,2014.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR DOMINO CL/CL 5.5/5.5 X_779125555 X_MEDTR,10351630,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR DOMINO CL/CL 5.5/5.5 X_779125555 X_MEDTR,10351630,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BLADDER LUMAX 10F,10351632,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,152.65,,,percent of total billed charges,,,,,,,,service not payable,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH STR TIP LUMAX 10F,10351633,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,152.65,,,percent of total billed charges,,,,,,,,service not payable,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE VASC TELE GEC 6F,10351634,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2077.00,623.10,882.73,1765.45,,1283.59,,,percent of total billed charges,,,,,,,,service not payable,1013.58,,,percent of total billed charges,,,1047.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,882.73,,,percent of total billed charges,,,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,,,,,,,service not payable,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1765.45,,,percent of total billed charges,,,955.42,,,percent of total billed charges,,,,,,,,,1350.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1350.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE VASC TELE GEC 7F,10351635,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2077.00,623.10,882.73,1765.45,,1283.59,,,percent of total billed charges,,,,,,,,service not payable,1013.58,,,percent of total billed charges,,,1047.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,882.73,,,percent of total billed charges,,,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,,,,,,,service not payable,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1765.45,,,percent of total billed charges,,,955.42,,,percent of total billed charges,,,,,,,,,1350.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1350.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 10X12.5,10351636,CDM,0278,RC,A2007,HCPCS,,,,,,inpatient,facility,,,14752.00,4425.60,5723.78,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5723.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12539.20,,,percent of total billed charges,,,6638.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX WOUND RESTRATA 10X12.5,10351636,CDM,0278,RC,A2007,HCPCS,,,,,,outpatient,facility,,,14752.00,4425.60,6195.84,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7440.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11064.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12539.20,,,percent of total billed charges,,,6785.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 10X12.5,10351636,CDM,0278,RC,A2007,HCPCS,2010,EAPG,,,,outpatient,facility,,,14752.00,4425.60,220.0,220.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MATRIX WOUND RESTRATA 5X5,10351637,CDM,0278,RC,A2007,HCPCS,,,,,,inpatient,facility,,,9180.00,2754.00,3561.84,7803.0,,4498.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3855.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3561.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4590.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.0,,,percent of total billed charges,,,4131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX WOUND RESTRATA 5X5,10351637,CDM,0278,RC,A2007,HCPCS,,,,,,outpatient,facility,,,9180.00,2754.00,3855.60,7803.0,,4498.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3855.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4630.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4590.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7803.0,,,percent of total billed charges,,,4222.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 5X5,10351637,CDM,0278,RC,A2007,HCPCS,2010,EAPG,,,,outpatient,facility,,,9180.00,2754.00,220.0,220.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Vaginectomy Partial,10351721,CDM,0490,RC,57106,CPT,,,,,,outpatient,facility,,,7406.00,2221.80,3406.76,6408.55,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,3735.59,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,5554.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,5554.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6295.10,,,percent of total billed charges,,,3406.76,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Vaginectomy Partial,10351721,CDM,0490,RC,57106,CPT,05414,APC,,,,outpatient,facility,,,7406.00,2221.80,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
END-Vaginectomy Partial,10351721,CDM,0490,RC,57106,CPT,188,EAPG,,,,outpatient,facility,,,7406.00,2221.80,3142.16,6582.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6582.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5594.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3142.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3456.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT ARTICULAR SZ5-6 11MM X_71453285 X_SMITH NEP,10351796,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ5-6 11MM X_71453285 X_SMITH NEP,10351796,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SINGLE PROBE 7MM X_OCP107 X_MEDTRONIC USA INC,10351797,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,10681.00,3204.30,4539.43,9078.85,,6600.86,,,percent of total billed charges,,,,,,,,service not payable,5212.33,,,percent of total billed charges,,,5387.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4539.43,,,percent of total billed charges,,,,,,,,,8010.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5340.5,,,percent of total billed charges,,,,,,,,service not payable,8010.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9078.85,,,percent of total billed charges,,,4913.26,,,percent of total billed charges,,,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SINGLE PROBE 10MM X_OCP110 X_MEDTRONIC USA INC,10351798,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,10681.00,3204.30,4539.43,9078.85,,6600.86,,,percent of total billed charges,,,,,,,,service not payable,5212.33,,,percent of total billed charges,,,5387.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4539.43,,,percent of total billed charges,,,,,,,,,8010.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5340.5,,,percent of total billed charges,,,,,,,,service not payable,8010.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9078.85,,,percent of total billed charges,,,4913.26,,,percent of total billed charges,,,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SINGLE PROBE 15MM X_OCP115 X_MEDTRONIC USA INC,10351799,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,10681.00,3204.30,4539.43,9078.85,,6600.86,,,percent of total billed charges,,,,,,,,service not payable,5212.33,,,percent of total billed charges,,,5387.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4539.43,,,percent of total billed charges,,,,,,,,,8010.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5340.5,,,percent of total billed charges,,,,,,,,service not payable,8010.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9078.85,,,percent of total billed charges,,,4913.26,,,percent of total billed charges,,,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SINGLE PROBE 20MM X_OCP120 X_MEDTRONIC USA INC,10351800,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,10681.00,3204.30,4539.43,9078.85,,6600.86,,,percent of total billed charges,,,,,,,,service not payable,5212.33,,,percent of total billed charges,,,5387.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4539.43,,,percent of total billed charges,,,,,,,,,8010.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5340.5,,,percent of total billed charges,,,,,,,,service not payable,8010.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9078.85,,,percent of total billed charges,,,4913.26,,,percent of total billed charges,,,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6942.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DUAL PROBE 7MM X_OCP207 X_MEDTRONIC USA INC,10351801,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,13654.00,4096.20,5802.95,11605.9,,8438.17,,,percent of total billed charges,,,,,,,,service not payable,6663.15,,,percent of total billed charges,,,6887.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5802.95,,,percent of total billed charges,,,,,,,,,10240.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6827.0,,,percent of total billed charges,,,,,,,,service not payable,10240.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11605.9,,,percent of total billed charges,,,6280.84,,,percent of total billed charges,,,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DUAL PROBE 10MM X_OCP210 X_MEDTRONIC USA INC,10351802,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,13654.00,4096.20,5802.95,11605.9,,8438.17,,,percent of total billed charges,,,,,,,,service not payable,6663.15,,,percent of total billed charges,,,6887.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5802.95,,,percent of total billed charges,,,,,,,,,10240.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6827.0,,,percent of total billed charges,,,,,,,,service not payable,10240.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11605.9,,,percent of total billed charges,,,6280.84,,,percent of total billed charges,,,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DUAL PROBE 15MM X_OCP215 X_MEDTRONIC USA INC,10351803,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,13654.00,4096.20,5802.95,11605.9,,8438.17,,,percent of total billed charges,,,,,,,,service not payable,6663.15,,,percent of total billed charges,,,6887.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5802.95,,,percent of total billed charges,,,,,,,,,10240.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6827.0,,,percent of total billed charges,,,,,,,,service not payable,10240.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11605.9,,,percent of total billed charges,,,6280.84,,,percent of total billed charges,,,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DUAL PROBE 20MM X_OCP220 X_MEDTRONIC USA INC,10351804,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,13654.00,4096.20,5802.95,11605.9,,8438.17,,,percent of total billed charges,,,,,,,,service not payable,6663.15,,,percent of total billed charges,,,6887.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5802.95,,,percent of total billed charges,,,,,,,,,10240.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6827.0,,,percent of total billed charges,,,,,,,,service not payable,10240.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11605.9,,,percent of total billed charges,,,6280.84,,,percent of total billed charges,,,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8875.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ITC 20G X_OCN001 X_MEDTRONIC USA INC,10351805,CDM,0272,RC,C1886,HCPCS,,,,,,outpatient,facility,,,1489.00,446.70,632.83,1265.65,,920.20,,,percent of total billed charges,,,,,,,,service not payable,726.63,,,percent of total billed charges,,,751.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,632.83,,,percent of total billed charges,,,,,,,,,1116.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,744.5,,,percent of total billed charges,,,,,,,,service not payable,1116.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1265.65,,,percent of total billed charges,,,684.94,,,percent of total billed charges,,,,,,,,,967.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,967.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT BONE ACCESS 10G X_OCN002 X_MEDTRONIC USA INC,10351806,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1321.00,396.30,512.55,1122.85,,,,,,,,,,,,,,,,,,,,512.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1122.85,,,percent of total billed charges,,,594.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT BONE ACCESS 10G X_OCN002 X_MEDTRONIC USA INC,10351806,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1321.00,396.30,561.42,1122.85,,,,,,,,,,,,,service not payable,,,,,,,666.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,990.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1122.85,,,percent of total billed charges,,,607.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT BONE ACCESS 8G X_OCN003 X_MEDTRONIC USA INC,10351807,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1321.00,396.30,512.55,1122.85,,,,,,,,,,,,,,,,,,,,512.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1122.85,,,percent of total billed charges,,,594.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT BONE ACCESS 8G X_OCN003 X_MEDTRONIC USA INC,10351807,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1321.00,396.30,561.42,1122.85,,,,,,,,,,,,,service not payable,,,,,,,666.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,990.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1122.85,,,percent of total billed charges,,,607.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT BONE ACCESS 10G X_OCN004 X_MEDTRONIC USA INC,10351808,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1321.00,396.30,512.55,1122.85,,,,,,,,,,,,,,,,,,,,512.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1122.85,,,percent of total billed charges,,,594.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT BONE ACCESS 10G X_OCN004 X_MEDTRONIC USA INC,10351808,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1321.00,396.30,561.42,1122.85,,,,,,,,,,,,,service not payable,,,,,,,666.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,990.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1122.85,,,percent of total billed charges,,,607.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT BONE ACCESS 13G X_OCN005 X_MEDTRONIC USA INC,10351809,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1321.00,396.30,512.55,1122.85,,,,,,,,,,,,,,,,,,,,512.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1122.85,,,percent of total billed charges,,,594.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT BONE ACCESS 13G X_OCN005 X_MEDTRONIC USA INC,10351809,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1321.00,396.30,561.42,1122.85,,,,,,,,,,,,,service not payable,,,,,,,666.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,561.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,990.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,660.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,990.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1122.85,,,percent of total billed charges,,,607.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FX-11-T 350ML X_133S-FX-11-T X_ALLER,10351810,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FX-11-T 350ML X_133S-FX-11-T X_ALLER,10351810,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FX-12-T 450ML,10351811,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FX-12-T 450ML,10351811,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FX-13-T 550ML,10351812,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FX-13-T 550ML,10351812,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FX-14-T 650ML,10351813,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FX-14-T 650ML,10351813,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FX-15-T 800ML,10351814,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FX-15-T 800ML,10351814,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FX-16-T 950ML X_133S-FX-16-T X_ALLER,10351815,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FX-16-T 950ML X_133S-FX-16-T X_ALLER,10351815,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MX-11-T 300ML,10351816,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MX-11-T 300ML,10351816,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MX-12-T 400ML,10351817,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MX-12-T 400ML,10351817,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MX-13-T 500ML,10351818,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MX-13-T 500ML,10351818,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MX-14-T 600ML,10351819,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MX-14-T 600ML,10351819,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MX-15-T 700ML,10351820,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MX-15-T 700ML,10351820,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MX-16-T 850ML,10351821,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MX-16-T 850ML,10351821,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SX-11-T 250ML X_133S-SX-11-T X_ALLER,10351822,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SX-11-T 250ML X_133S-SX-11-T X_ALLER,10351822,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SX-12-T 350ML,10351823,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SX-12-T 350ML,10351823,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SX-13-T 400ML X_133S-SX-13-T X_ALLER,10351824,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SX-13-T 400ML X_133S-SX-13-T X_ALLER,10351824,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SX-14-T 500ML,10351825,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SX-14-T 500ML,10351825,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SX-15-T 650ML,10351826,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SX-15-T 650ML,10351826,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SX-16-T 800ML,10351827,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SX-16-T 800ML,10351827,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FV-11-T 300ML X_133S-FV-11-T X_ALLER,10351828,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FV-11-T 300ML X_133S-FV-11-T X_ALLER,10351828,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FV-12-T 400ML X_133S-FV-12-T X_ALLER,10351829,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FV-12-T 400ML X_133S-FV-12-T X_ALLER,10351829,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FV-13-T 500ML X_133S-FV-13-T X_ALLER,10351830,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FV-13-T 500ML X_133S-FV-13-T X_ALLER,10351830,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FV-14-T 600ML X_133S-FV-14-T X_ALLER,10351831,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FV-14-T 600ML X_133S-FV-14-T X_ALLER,10351831,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FV-15-T 750ML X_133S-FV-15-T X_ALLER,10351832,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FV-15-T 750ML X_133S-FV-15-T X_ALLER,10351832,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH FV-16-T 850ML X_133S-FV-16-T X_ALLER,10351833,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH FV-16-T 850ML X_133S-FV-16-T X_ALLER,10351833,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MV-11-T 250ML,10351834,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MV-11-T 250ML,10351834,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MV-12-T 300ML,10351835,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MV-12-T 300ML,10351835,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MV-13-T 400ML,10351836,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MV-13-T 400ML,10351836,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MV-14-T 500ML,10351837,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MV-14-T 500ML,10351837,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH MV-16-T 700ML X_133S-MV-16-T X_ALLER,10351839,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH MV-16-T 700ML X_133S-MV-16-T X_ALLER,10351839,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SV-11-T 200ML X_133S-SV-11-T X_ALLER,10351840,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SV-11-T 200ML X_133S-SV-11-T X_ALLER,10351840,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SV-12-T 250ML X_133S-SV-12-T X_ALLER,10351841,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SV-12-T 250ML X_133S-SV-12-T X_ALLER,10351841,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SV-13-T 300ML X_133S-SV-13-T X_ALLER,10351842,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SV-13-T 300ML X_133S-SV-13-T X_ALLER,10351842,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SV-14-T 375ML X_133S-SV-14-T X_ALLER,10351843,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SV-14-T 375ML X_133S-SV-14-T X_ALLER,10351843,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SV-15-T 450ML X_133S-SV-15-T X_ALLER,10351844,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SV-15-T 450ML X_133S-SV-15-T X_ALLER,10351844,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER SMTH SV-16-T 500ML X_133S-SV-16-T X_ALLER,10351845,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER SMTH SV-16-T 500ML X_133S-SV-16-T X_ALLER,10351845,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST CPX4 TALL 550ML X_354-9314 X_MENTOR,10352061,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5557.00,1667.10,2156.12,4723.45,,2722.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2333.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2156.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2361.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4167.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2778.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4723.45,,,percent of total billed charges,,,2500.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST CPX4 TALL 550ML X_354-9314 X_MENTOR,10352061,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5557.00,1667.10,2333.94,4723.45,,2722.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2333.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2802.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2361.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4167.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2778.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4167.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4723.45,,,percent of total billed charges,,,2556.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 1 LVL 26MM,10352062,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 1 LVL 26MM,10352062,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK COMP HEX 40X6.5MM,10352065,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,437.00,131.10,169.56,371.45,,,,,,,,,,,,,,,,,,,,169.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,196.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK COMP HEX 40X6.5MM,10352065,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,,,,,,,,,,,,service not payable,,,,,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS RP INSRT SZ 4 8MM,10352852,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS RP INSRT SZ 4 8MM,10352852,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS RP INSRT SZ 4 6MM,10352853,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS RP INSRT SZ 4 6MM,10352853,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS FEM RT SZ 4 CEM,10352854,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEM RT SZ 4 CEM,10352854,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ2 10MM X_5531-G-210-E X_STRYKER OR,10352855,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ2 10MM X_5531-G-210-E X_STRYKER OR,10352855,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URET DBL PIGTAIL 6F 22CM,10352857,CDM,0272,RC,C2617,HCPCS,,,,,,outpatient,facility,,,714.00,214.20,303.45,606.90,,441.25,,,percent of total billed charges,,,,,,,,service not payable,348.43,,,percent of total billed charges,,,360.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.45,,,percent of total billed charges,,,,,,,,,535.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,service not payable,535.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,606.90,,,percent of total billed charges,,,328.44,,,percent of total billed charges,,,,,,,,,464.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH HSG 5F 30CM,10352858,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,139.40,,101.35,,,percent of total billed charges,,,,,,,,service not payable,80.03,,,percent of total billed charges,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.70,,,percent of total billed charges,,,,,,,,,123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.0,,,percent of total billed charges,,,,,,,,service not payable,123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,106.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,106.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE CERTAS SM PROGRAMMABLE,10352859,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,16374.00,4912.20,6353.11,13917.9,,8023.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6877.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6353.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6958.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8187.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13917.9,,,percent of total billed charges,,,7368.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE CERTAS SM PROGRAMMABLE,10352859,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,16374.00,4912.20,6877.08,13917.9,,8023.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6877.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8259.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6958.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12280.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8187.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12280.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13917.9,,,percent of total billed charges,,,7532.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 12F 12CM X_407655 X_ABBOTT LABOR,10352860,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,125.00,37.50,53.13,106.25,,77.25,,,percent of total billed charges,,,,,,,,service not payable,61.0,,,percent of total billed charges,,,63.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,53.13,,,percent of total billed charges,,,,,,,,,93.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,62.5,,,percent of total billed charges,,,,,,,,service not payable,93.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,106.25,,,percent of total billed charges,,,57.5,,,percent of total billed charges,,,,,,,,,81.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,81.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 7.5X7.5,10352861,CDM,0278,RC,A2007,HCPCS,,,,,,inpatient,facility,,,11065.00,3319.50,4293.22,9405.25,,5421.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4647.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4293.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4702.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8298.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5532.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9405.25,,,percent of total billed charges,,,4979.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX WOUND RESTRATA 7.5X7.5,10352861,CDM,0278,RC,A2007,HCPCS,,,,,,outpatient,facility,,,11065.00,3319.50,4647.30,9405.25,,5421.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4647.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5581.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4702.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8298.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5532.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8298.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9405.25,,,percent of total billed charges,,,5089.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 7.5X7.5,10352861,CDM,0278,RC,A2007,HCPCS,2010,EAPG,,,,outpatient,facility,,,11065.00,3319.50,220.0,220.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
IMPLANT ORBIT PERF HA 20MM X_I0020P X_INTEGRATED O,10352862,CDM,0278,RC,L8610,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT ORBIT PERF HA 20MM X_I0020P X_INTEGRATED O,10352862,CDM,0278,RC,L8610,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 22.0 D 6MM,10352863,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 22.0 D 6MM,10352863,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 24.5,10352864,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 24.5,10352864,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 15.0,10352865,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 15.0,10352865,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NUCLEUS SLIM PROFILE CI632,10352866,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,47089.00,14126.70,18270.53,40025.65,,23073.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19777.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,18270.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20012.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,35316.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23544.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40025.65,,,percent of total billed charges,,,21190.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NUCLEUS SLIM PROFILE CI632,10352866,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,47089.00,14126.70,19777.38,40025.65,,23073.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19777.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,23751.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,20012.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,35316.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,23544.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,35316.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,40025.65,,,percent of total billed charges,,,21660.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST FEM NCB PP 317MM RT,10352867,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5477.00,1643.10,2125.08,4655.45,,2683.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2300.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2125.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2327.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2738.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4655.45,,,percent of total billed charges,,,2464.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST FEM NCB PP 317MM RT,10352867,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5477.00,1643.10,2300.34,4655.45,,2683.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2300.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2762.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2327.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4107.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2738.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4107.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4655.45,,,percent of total billed charges,,,2519.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 2.5X2.5,10352868,CDM,0278,RC,A2007,HCPCS,,,,,,inpatient,facility,,,4275.00,1282.50,1658.7,3633.75,,,,,,,,,,,,,,,,,,,,1658.7,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1816.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3206.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2137.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3633.75,,,percent of total billed charges,,,1923.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX WOUND RESTRATA 2.5X2.5,10352868,CDM,0278,RC,A2007,HCPCS,,,,,,outpatient,facility,,,4275.00,1282.50,1816.88,3633.75,,,,,,,,,,,,,service not payable,,,,,,,2156.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1816.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3206.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2137.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3206.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3633.75,,,percent of total billed charges,,,1966.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 2.5X2.5,10352868,CDM,0278,RC,A2007,HCPCS,2010,EAPG,,,,outpatient,facility,,,4275.00,1282.50,220.0,220.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MATRIX WOUND RESTRATA 2.5X5CM,10352869,CDM,0278,RC,A2007,HCPCS,,,,,,inpatient,facility,,,5328.00,1598.40,2067.26,4528.80,,2610.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2237.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2067.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2264.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3996.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2664.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4528.80,,,percent of total billed charges,,,2397.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX WOUND RESTRATA 2.5X5CM,10352869,CDM,0278,RC,A2007,HCPCS,,,,,,outpatient,facility,,,5328.00,1598.40,2237.76,4528.80,,2610.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2237.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2687.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2264.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3996.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2664.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3996.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4528.80,,,percent of total billed charges,,,2450.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 2.5X5CM,10352869,CDM,0278,RC,A2007,HCPCS,2010,EAPG,,,,outpatient,facility,,,5328.00,1598.40,220.0,220.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MATRIX WOUND RESTRATA 2.5X7.5,10352870,CDM,0278,RC,A2007,HCPCS,,,,,,inpatient,facility,,,9180.00,2754.00,3561.84,7803.0,,4498.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3855.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3561.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4590.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.0,,,percent of total billed charges,,,4131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX WOUND RESTRATA 2.5X7.5,10352870,CDM,0278,RC,A2007,HCPCS,,,,,,outpatient,facility,,,9180.00,2754.00,3855.60,7803.0,,4498.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3855.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4630.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4590.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7803.0,,,percent of total billed charges,,,4222.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX WOUND RESTRATA 2.5X7.5,10352870,CDM,0278,RC,A2007,HCPCS,2010,EAPG,,,,outpatient,facility,,,9180.00,2754.00,220.0,220.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,220.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH TRAY PNEUMOTHOR 14F 29CM,10352873,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,1151.00,345.30,489.18,978.35,,711.32,,,percent of total billed charges,,,,,,,,service not payable,561.69,,,percent of total billed charges,,,580.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,489.18,,,percent of total billed charges,,,,,,,,,863.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,575.5,,,percent of total billed charges,,,,,,,,service not payable,863.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,978.35,,,percent of total billed charges,,,529.46,,,percent of total billed charges,,,,,,,,,748.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,748.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN PL PF 3.5X18MM,10352874,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,488.00,146.40,189.34,414.80,,,,,,,,,,,,,,,,,,,,189.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,366.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,244.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.80,,,percent of total billed charges,,,219.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN PL PF 3.5X18MM,10352874,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,488.00,146.40,207.40,414.80,,,,,,,,,,,,,service not payable,,,,,,,246.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,207.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,366.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,244.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,366.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,414.80,,,percent of total billed charges,,,224.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SS 22MM 6.5X145MM X_71106645S X_SMITH N,10352875,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1088.00,326.40,422.14,924.80,,,,,,,,,,,,,,,,,,,,422.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,816.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,544.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,924.80,,,percent of total billed charges,,,489.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SS 22MM 6.5X145MM X_71106645S X_SMITH N,10352875,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1088.00,326.40,462.40,924.80,,,,,,,,,,,,,service not payable,,,,,,,548.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,462.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,816.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,544.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,816.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,924.80,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROTECTOR SKIN NONSTER NAIL,10352876,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,956.00,286.80,370.93,812.60,,,,,,,,,,,,,,,,,,,,370.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.60,,,percent of total billed charges,,,430.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTECTOR SKIN NONSTER NAIL,10352876,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,956.00,286.80,406.30,812.60,,,,,,,,,,,,,service not payable,,,,,,,482.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,717.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,812.60,,,percent of total billed charges,,,439.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER HUM ROUND 17MM X_1830-0008S X_STRYKER ORTHO,10352877,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,821.00,246.30,318.55,697.85,,,,,,,,,,,,,,,,,,,,318.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.85,,,percent of total billed charges,,,369.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER HUM ROUND 17MM X_1830-0008S X_STRYKER ORTHO,10352877,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,821.00,246.30,348.93,697.85,,,,,,,,,,,,,service not payable,,,,,,,414.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.85,,,percent of total billed charges,,,377.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TRILOCK ULNA SHORTENING,10352878,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TRILOCK ULNA SHORTENING,10352878,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI 14X2.5MM,10352879,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,557.00,167.10,216.12,473.45,,,,,,,,,,,,,,,,,,,,216.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,417.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,278.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.45,,,percent of total billed charges,,,250.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI 14X2.5MM,10352879,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,557.00,167.10,236.72,473.45,,,,,,,,,,,,,service not payable,,,,,,,280.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,236.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,417.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,278.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,417.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,473.45,,,percent of total billed charges,,,256.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI 15X2.5MM X_A-5700.15/1 X_MEDART,10352880,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,558.00,167.40,216.50,474.30,,,,,,,,,,,,,,,,,,,,216.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,418.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,474.30,,,percent of total billed charges,,,251.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI 15X2.5MM X_A-5700.15/1 X_MEDART,10352880,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,558.00,167.40,237.15,474.30,,,,,,,,,,,,,service not payable,,,,,,,281.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,418.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,279.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,418.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,474.30,,,percent of total billed charges,,,256.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI 16X2.5MM,10352881,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,558.00,167.40,216.50,474.30,,,,,,,,,,,,,,,,,,,,216.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,418.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,474.30,,,percent of total billed charges,,,251.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI 16X2.5MM,10352881,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,558.00,167.40,237.15,474.30,,,,,,,,,,,,,service not payable,,,,,,,281.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,418.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,279.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,418.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,474.30,,,percent of total billed charges,,,256.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI 18X2.5MM,10352882,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,558.00,167.40,216.50,474.30,,,,,,,,,,,,,,,,,,,,216.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,418.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,474.30,,,percent of total billed charges,,,251.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI 18X2.5MM,10352882,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,558.00,167.40,237.15,474.30,,,,,,,,,,,,,service not payable,,,,,,,281.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,418.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,279.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,418.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,474.30,,,percent of total billed charges,,,256.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT TENSION TEMPORARY,10352885,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,897.00,269.10,348.04,762.45,,,,,,,,,,,,,,,,,,,,348.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,672.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,448.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,762.45,,,percent of total billed charges,,,403.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT TENSION TEMPORARY,10352885,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,897.00,269.10,381.22,762.45,,,,,,,,,,,,,service not payable,,,,,,,452.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,381.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,672.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,448.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,672.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,762.45,,,percent of total billed charges,,,412.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI LK 14X2.5MM,10352886,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI LK 14X2.5MM,10352886,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI LK 16X2.5MM,10352887,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,901.00,270.30,349.59,765.85,,,,,,,,,,,,,,,,,,,,349.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,675.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,450.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,765.85,,,percent of total billed charges,,,405.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI LK 16X2.5MM,10352887,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,901.00,270.30,382.93,765.85,,,,,,,,,,,,,service not payable,,,,,,,454.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,382.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,675.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,450.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,675.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,765.85,,,percent of total billed charges,,,414.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 22.5 D 6MM,10352889,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 22.5 D 6MM,10352889,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 27,10352892,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 27,10352892,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 27.5,10352893,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 27.5,10352893,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 8.5,10352894,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 8.5,10352894,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 9.5,10352895,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 9.5,10352895,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 16,10352896,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 16,10352896,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 26.5,10352897,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 26.5,10352897,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 10.5,10352898,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 10.5,10352898,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 11,10352899,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 11,10352899,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 12.5,10352900,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 12.5,10352900,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 24.5,10352901,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 24.5,10352901,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 26.0,10352902,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 26.0,10352902,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 27.0,10352903,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 27.0,10352903,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 29.0,10352904,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 29.0,10352904,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 6.0D 14.0,10352906,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 6.0D 14.0,10352906,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SET YUKON,10353260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SET YUKON,10353260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW YUKON POLYAXIAL 3.5X14MM,10353261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW YUKON POLYAXIAL 3.5X14MM,10353261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD YUKON CONTOURED 3.5X55MM,10353262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD YUKON CONTOURED 3.5X55MM,10353262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL HEXD 7 12X2.5MM,10353263,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,901.00,270.30,349.59,765.85,,,,,,,,,,,,,,,,,,,,349.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,675.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,450.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,765.85,,,percent of total billed charges,,,405.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL HEXD 7 12X2.5MM,10353263,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,901.00,270.30,382.93,765.85,,,,,,,,,,,,,service not payable,,,,,,,454.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,382.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,675.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,450.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,675.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,765.85,,,percent of total billed charges,,,414.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6X80MM X_608480 X_STRYKER ORTHOPAEDICS,10353264,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6X80MM X_608480 X_STRYKER ORTHOPAEDICS,10353264,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6X90MM X_608490 X_STRYKER ORTHOPAEDICS,10353265,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6X90MM X_608490 X_STRYKER ORTHOPAEDICS,10353265,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC 6X95MM X_608495 X_STRYKER ORTHOPAEDICS,10353266,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC 6X95MM X_608495 X_STRYKER ORTHOPAEDICS,10353266,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5X48MM X_661148 X_STRYKER ORTHOPAEDICS,10353267,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5X48MM X_661148 X_STRYKER ORTHOPAEDICS,10353267,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5X50MM X_661150 X_STRYKER ORTHOPAEDICS,10353268,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5X50MM X_661150 X_STRYKER ORTHOPAEDICS,10353268,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARI OZARK ST 4X14MM,10353269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARI OZARK ST 4X14MM,10353269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 2 LVL 34MM,10353270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 2 LVL 34MM,10353270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ5 10MM X_5532-G-510-E X_ST,10353271,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ5 10MM X_5532-G-510-E X_ST,10353271,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM OXIN NP BCS SZ4 LT,10353272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM OXIN NP BCS SZ4 LT,10353272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR LT SZ3-4 9MM X_74027241 X-SMITH N,10353273,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR LT SZ3-4 9MM X_74027241 X-SMITH N,10353273,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC PRESTIGE CERVICAL LP 5X16MM X_6972650 X_MEDTR,10353275,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15901.00,4770.30,6169.59,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6169.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13515.85,,,percent of total billed charges,,,7155.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC PRESTIGE CERVICAL LP 5X16MM X_6972650 X_MEDTR,10353275,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15901.00,4770.30,6678.42,13515.85,,7791.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6678.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8020.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6757.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13515.85,,,percent of total billed charges,,,7314.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 6H TIBIAL PROX LT X_7180-0206 X_SMITH NEPHEW,10353276,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3679.00,1103.70,1427.45,3127.15,,,,,,,,,,,,,,,,,,,,1427.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1563.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2759.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3127.15,,,percent of total billed charges,,,1655.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 6H TIBIAL PROX LT X_7180-0206 X_SMITH NEPHEW,10353276,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3679.00,1103.70,1563.58,3127.15,,,,,,,,,,,,,service not payable,,,,,,,1855.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1563.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2759.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1839.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2759.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3127.15,,,percent of total billed charges,,,1692.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE IFUSE LF TI 3.2MM,10353277,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE IFUSE LF TI 3.2MM,10353277,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN BLUNT IFUSE LF TI 3.2MM,10353278,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN BLUNT IFUSE LF TI 3.2MM,10353278,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN EXCHANGE IFUSE LF TI 3.2MM,10353279,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN EXCHANGE IFUSE LF TI 3.2MM,10353279,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC NCB PROT 65X5MM,10353348,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,888.00,266.40,344.54,754.80,,,,,,,,,,,,,,,,,,,,344.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,666.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,444.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,,399.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC NCB PROT 65X5MM,10353348,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,888.00,266.40,377.40,754.80,,,,,,,,,,,,,service not payable,,,,,,,447.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,377.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,666.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,444.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,666.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,,408.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT SAC IFUSE 7.0X60MM,10353351,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT SAC IFUSE 7.0X60MM,10353351,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETABULAR 60MM X_702-11-60G X_STRYKER ORTHO,10353352,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR 60MM X_702-11-60G X_STRYKER ORTHO,10353352,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIBIAL DISTAL LT 6H X_71820606 X_SMITH NEPHE,10353353,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3859.00,1157.70,1497.29,3280.15,,,,,,,,,,,,,,,,,,,,1497.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1640.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2894.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3280.15,,,percent of total billed charges,,,1736.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIBIAL DISTAL LT 6H X_71820606 X_SMITH NEPHE,10353353,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3859.00,1157.70,1640.08,3280.15,,,,,,,,,,,,,service not payable,,,,,,,1946.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1640.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2894.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2894.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3280.15,,,percent of total billed charges,,,1775.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SENSAR 6.0,10353354,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,956.00,286.80,370.93,812.60,,,,,,,,,,,,,,,,,,,,370.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.60,,,percent of total billed charges,,,430.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SENSAR 6.0,10353354,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,956.00,286.80,406.30,812.60,,,,,,,,,,,,,service not payable,,,,,,,482.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,717.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,812.60,,,percent of total billed charges,,,439.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Aldosterone,10353386,CDM,0300,RC,82088,CPT,,,,,,outpatient,facility,,,64.00,19.20,29.44,92.09,,64.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,39.93,,,fee schedule,,,64.0,,,fee schedule,,,84.98,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,84.35,,,fee schedule,,,38.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",40.73,,,fee schedule,,,92.09,,,fee schedule,,,,,,,,,39.93,,,fee schedule,,,,,,,,,52.23,,,fee schedule,,,83.13,,,fee schedule,,,48.0,,,percent of total billed charges,,,39.93,,,fee schedule,,,38.71,,,fee schedule,,,40.73,,,fee schedule,,,61.43,,,fee schedule,,,39.93,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,40.73,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,44.83,,,fee schedule,,,39.93,,,fee schedule,,,,,,,,,39.53,,,fee schedule,,,39.93,,,fee schedule,,,,,,,,,40.34,,,fee schedule,,,,,,,,
Aldosterone,10353386,CDM,0300,RC,82088,CPT,399,EAPG,,,,outpatient,facility,,,64.00,19.20,41.30,150.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,128.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,41.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,41.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,90.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Renin Activity,10353387,CDM,0300,RC,84244,CPT,,,,,,outpatient,facility,,,64.00,19.20,20.89,64.0,,64.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,21.55,,,fee schedule,,,64.0,,,fee schedule,,,45.86,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,45.52,,,fee schedule,,,20.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.98,,,fee schedule,,,49.70,,,fee schedule,,,,,,,,,21.55,,,fee schedule,,,,,,,,,28.23,,,fee schedule,,,44.86,,,fee schedule,,,48.0,,,percent of total billed charges,,,21.55,,,fee schedule,,,20.89,,,fee schedule,,,21.98,,,fee schedule,,,33.20,,,fee schedule,,,21.55,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,21.98,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,24.19,,,fee schedule,,,21.55,,,fee schedule,,,,,,,,,21.33,,,fee schedule,,,21.55,,,fee schedule,,,,,,,,,21.77,,,fee schedule,,,,,,,,
Renin Activity,10353387,CDM,0300,RC,84244,CPT,398,EAPG,,,,outpatient,facility,,,64.00,19.20,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW UNICORT NCB 12X5MM,10353695,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,959.00,287.70,372.09,815.15,,,,,,,,,,,,,,,,,,,,372.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,719.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,815.15,,,percent of total billed charges,,,431.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW UNICORT NCB 12X5MM,10353695,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,959.00,287.70,407.57,815.15,,,,,,,,,,,,,service not payable,,,,,,,483.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,407.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,719.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,479.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,719.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,815.15,,,percent of total billed charges,,,441.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM ENDURANCE SZ3 145MM,10354205,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20456.00,6136.80,7936.93,17387.60,,10023.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8591.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7936.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8693.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15342.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10228.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17387.60,,,percent of total billed charges,,,9205.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM ENDURANCE SZ3 145MM,10354205,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20456.00,6136.80,8591.52,17387.60,,10023.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8591.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10318.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8693.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15342.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10228.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15342.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17387.60,,,percent of total billed charges,,,9409.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 14H NARROW 4.5X260MM,10354206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4213.00,1263.90,1634.64,3581.05,,,,,,,,,,,,,,,,,,,,1634.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3159.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3581.05,,,percent of total billed charges,,,1895.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 14H NARROW 4.5X260MM,10354206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4213.00,1263.90,1790.52,3581.05,,,,,,,,,,,,,service not payable,,,,,,,2125.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1790.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3159.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3159.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3581.05,,,percent of total billed charges,,,1937.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 4.5X48 X_AR-8545L-48 X_ARTHREX INC,10354207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 4.5X48 X_AR-8545L-48 X_ARTHREX INC,10354207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 5X65MM X_AR-8750-65H X_ARTHREX INC,10354208,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 5X65MM X_AR-8750-65H X_ARTHREX INC,10354208,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMAX W/INST 20WX20L,10354210,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8180.00,2454.00,3173.84,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3173.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6953.0,,,percent of total billed charges,,,3681.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMAX W/INST 20WX20L,10354210,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8180.00,2454.00,3435.60,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4125.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6953.0,,,percent of total billed charges,,,3762.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 5TH METATARSAL LONG RT X_AR-8956R-03 X_ARTHR,10354211,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4180.00,1254.00,1621.84,3553.0,,,,,,,,,,,,,,,,,,,,1621.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1776.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,,1881.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 5TH METATARSAL LONG RT X_AR-8956R-03 X_ARTHR,10354211,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4180.00,1254.00,1776.5,3553.0,,,,,,,,,,,,,service not payable,,,,,,,2108.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1776.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,,1922.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS 2.0X16 X_7240-2016 X_SMITH NEPHEW,10354212,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS 2.0X16 X_7240-2016 X_SMITH NEPHEW,10354212,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS 2.0X18 X_7240-2018 X_SMITH NEPHEW,10354213,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,170.00,51.00,65.96,144.5,,,,,,,,,,,,,,,,,,,,65.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS 2.0X18 X_7240-2018 X_SMITH NEPHEW,10354213,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,170.00,51.00,72.25,144.5,,,,,,,,,,,,,service not payable,,,,,,,85.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,127.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,127.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 4D 8X11X25MM,10354214,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 8X11X25MM,10354214,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT WIRE M 1.5-2.0MM X_4933-1-002 X_STRYKER,10354218,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT WIRE M 1.5-2.0MM X_4933-1-002 X_STRYKER,10354218,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT WIRE L 1.5-2.0MM X_4933-1-003 X_STRYKER,10354219,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT WIRE L 1.5-2.0MM X_4933-1-003 X_STRYKER,10354219,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT FOR RING X_4933-1-702 X_STRYKER,10354225,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,140.00,42.00,54.32,119.0,,,,,,,,,,,,,,,,,,,,54.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,,63.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT FOR RING X_4933-1-702 X_STRYKER,10354225,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,140.00,42.00,59.5,119.0,,,,,,,,,,,,,service not payable,,,,,,,70.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,105.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,,64.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SLOTTED X_4934-1-060 X_STRYKER,10354228,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1175.00,352.50,455.90,998.75,,,,,,,,,,,,,,,,,,,,455.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,499.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,881.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,587.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,,528.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SLOTTED X_4934-1-060 X_STRYKER,10354228,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1175.00,352.50,499.38,998.75,,,,,,,,,,,,,service not payable,,,,,,,592.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,499.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,881.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,587.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,881.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,540.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FOOT ARCH 180MM X_4934-6-180 X_STRYKER,10354231,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6027.00,1808.10,2338.48,5122.95,,2953.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2531.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2338.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2561.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4520.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3013.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5122.95,,,percent of total billed charges,,,2712.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOOT ARCH 180MM X_4934-6-180 X_STRYKER,10354231,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6027.00,1808.10,2531.34,5122.95,,2953.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2531.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3040.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2561.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4520.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3013.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4520.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5122.95,,,percent of total billed charges,,,2772.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STRUT HEXAPOD SHT 105-139MM X_4935-0-020 X_STRYKER,10354233,CDM,0278,RC,C1734,HCPCS,,,,,,inpatient,facility,,,12391.00,3717.30,4807.71,10532.35,,6071.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5204.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4807.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5266.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9293.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6195.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10532.35,,,percent of total billed charges,,,5575.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STRUT HEXAPOD SHT 105-139MM X_4935-0-020 X_STRYKER,10354233,CDM,0278,RC,C1734,HCPCS,,,,,,outpatient,facility,,,12391.00,3717.30,5204.22,10532.35,,6071.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5204.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6250.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5266.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9293.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6195.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9293.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10532.35,,,percent of total billed charges,,,5699.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STRUT HEXAPOD MD 131-191MM X_4935-0-030 X_STRYKER,10354234,CDM,0278,RC,C1734,HCPCS,,,,,,inpatient,facility,,,12391.00,3717.30,4807.71,10532.35,,6071.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5204.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4807.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5266.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9293.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6195.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10532.35,,,percent of total billed charges,,,5575.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STRUT HEXAPOD MD 131-191MM X_4935-0-030 X_STRYKER,10354234,CDM,0278,RC,C1734,HCPCS,,,,,,outpatient,facility,,,12391.00,3717.30,5204.22,10532.35,,6071.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5204.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6250.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5266.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9293.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6195.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9293.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10532.35,,,percent of total billed charges,,,5699.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COUNTERSINK 1.7MM W/SHFTEND X_60-80117 X_STRYKER O,10354236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,637.00,191.10,247.16,541.45,,,,,,,,,,,,,,,,,,,,247.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,477.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,318.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,,286.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COUNTERSINK 1.7MM W/SHFTEND X_60-80117 X_STRYKER O,10354236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,637.00,191.10,270.72,541.45,,,,,,,,,,,,,service not payable,,,,,,,321.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,270.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,477.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,318.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,477.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,541.45,,,percent of total billed charges,,,293.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 8H TIBIAL LT X_7180-0208 X_SMITH NEPHEW,10354237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3715.00,1114.50,1441.42,3157.75,,,,,,,,,,,,,,,,,,,,1441.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3157.75,,,percent of total billed charges,,,1671.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 8H TIBIAL LT X_7180-0208 X_SMITH NEPHEW,10354237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3715.00,1114.50,1578.88,3157.75,,,,,,,,,,,,,service not payable,,,,,,,1873.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1578.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3157.75,,,percent of total billed charges,,,1708.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE STR 2.7MM 7H X_7244-2776 X_SMITH NEPHEW,10354238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3393.00,1017.90,1316.48,2884.05,,,,,,,,,,,,,,,,,,,,1316.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2884.05,,,percent of total billed charges,,,1526.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE STR 2.7MM 7H X_7244-2776 X_SMITH NEPHEW,10354238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3393.00,1017.90,1442.02,2884.05,,,,,,,,,,,,,service not payable,,,,,,,1711.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2884.05,,,percent of total billed charges,,,1560.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7X11MM X_7240-2711 X_SMITH NEP,10354239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7X11MM X_7240-2711 X_SMITH NEP,10354239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X20MM X_72412720 X_SMITH NEPHEW,10354240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X20MM X_72412720 X_SMITH NEPHEW,10354240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X40MM X_7241-2740 X_SMITH NEPHEW,10354241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X40MM X_7241-2740 X_SMITH NEPHEW,10354241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS 2.7X40MM X_7240-2740 X_SMITH NEPHEW,10354242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS 2.7X40MM X_7240-2740 X_SMITH NEPHEW,10354242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1 LEVEL 22MM OZARK,10354243,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1 LEVEL 22MM OZARK,10354243,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SCHANZ SELF DRL 4.0X80MM,10354246,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,837.00,251.10,324.76,711.45,,,,,,,,,,,,,,,,,,,,324.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,627.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.45,,,percent of total billed charges,,,376.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SCHANZ SELF DRL 4.0X80MM,10354246,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,837.00,251.10,355.72,711.45,,,,,,,,,,,,,service not payable,,,,,,,422.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,355.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,627.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,418.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,627.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,711.45,,,percent of total billed charges,,,385.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ASAHI MB 12 180CM,10354247,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SR 4.5X18MM X_601018 X_STRYKER ORTHOPAE,10354249,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,137.00,41.10,53.16,116.45,,,,,,,,,,,,,,,,,,,,53.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,61.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SR 4.5X18MM X_601018 X_STRYKER ORTHOPAE,10354249,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,137.00,41.10,58.23,116.45,,,,,,,,,,,,,service not payable,,,,,,,69.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,102.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOFORM DERMAL 2X2IN,10354250,CDM,0272,RC,A6021,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,43.26,,,percent of total billed charges,,,,,,,,service not payable,34.16,,,percent of total billed charges,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOFORM DERMAL 4X5IN,10354251,CDM,0272,RC,A6022,HCPCS,,,,,,outpatient,facility,,,200.00,60.00,85.0,170.0,,123.60,,,percent of total billed charges,,,,,,,,service not payable,97.60,,,percent of total billed charges,,,100.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,85.0,,,percent of total billed charges,,,,,,,,,150.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,100.0,,,percent of total billed charges,,,,,,,,service not payable,150.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,170.0,,,percent of total billed charges,,,92.0,,,percent of total billed charges,,,,,,,,,130.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,130.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC RESILIA 19MM,10354252,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,28397.00,8519.10,11018.04,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11018.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24137.45,,,percent of total billed charges,,,12778.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC RESILIA 19MM,10354252,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,28397.00,8519.10,11926.74,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14323.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24137.45,,,percent of total billed charges,,,13062.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC RESILIA 21MM,10354253,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,28397.00,8519.10,11018.04,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11018.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24137.45,,,percent of total billed charges,,,12778.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC RESILIA 21MM,10354253,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,28397.00,8519.10,11926.74,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14323.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24137.45,,,percent of total billed charges,,,13062.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC RESILIA 23MM,10354254,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,28397.00,8519.10,11018.04,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11018.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24137.45,,,percent of total billed charges,,,12778.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC RESILIA 23MM,10354254,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,28397.00,8519.10,11926.74,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14323.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24137.45,,,percent of total billed charges,,,13062.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC RESILIA 25MM,10354255,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,28397.00,8519.10,11018.04,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11018.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24137.45,,,percent of total billed charges,,,12778.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC RESILIA 25MM,10354255,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,28397.00,8519.10,11926.74,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14323.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24137.45,,,percent of total billed charges,,,13062.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC RESILIA 27MM,10354256,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,28397.00,8519.10,11018.04,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11018.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24137.45,,,percent of total billed charges,,,12778.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC RESILIA 27MM,10354256,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,28397.00,8519.10,11926.74,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14323.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24137.45,,,percent of total billed charges,,,13062.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC RESILIA 29MM,10354257,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,28397.00,8519.10,11018.04,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11018.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24137.45,,,percent of total billed charges,,,12778.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC RESILIA 29MM,10354257,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,28397.00,8519.10,11926.74,24137.45,,13914.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11926.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14323.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12068.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24137.45,,,percent of total billed charges,,,13062.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BASE LOCKING 2H6H 2MM,10354258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2986.00,895.80,1158.57,2538.10,,,,,,,,,,,,,,,,,,,,1158.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1269.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2239.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1493.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2538.10,,,percent of total billed charges,,,1343.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BASE LOCKING 2H6H 2MM,10354258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2986.00,895.80,1269.05,2538.10,,,,,,,,,,,,,service not payable,,,,,,,1506.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1269.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2239.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1493.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2239.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2538.10,,,percent of total billed charges,,,1373.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST FT STARDRV 2X8MM,10354259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,234.00,70.20,90.79,198.90,,,,,,,,,,,,,,,,,,,,90.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,175.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.90,,,percent of total billed charges,,,105.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST FT STARDRV 2X8MM,10354259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,234.00,70.20,99.45,198.90,,,,,,,,,,,,,service not payable,,,,,,,118.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,99.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,175.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,117.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,175.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,198.90,,,percent of total billed charges,,,107.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK STAR ST VAR 9X2MM,10354260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,843.00,252.90,327.08,716.55,,,,,,,,,,,,,,,,,,,,327.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,632.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,716.55,,,percent of total billed charges,,,379.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK STAR ST VAR 9X2MM,10354260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,843.00,252.90,358.27,716.55,,,,,,,,,,,,,service not payable,,,,,,,425.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,358.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,632.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,632.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,716.55,,,percent of total billed charges,,,387.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK VAR ANG ST 2X15MM,10354261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,843.00,252.90,327.08,716.55,,,,,,,,,,,,,,,,,,,,327.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,632.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,716.55,,,percent of total billed charges,,,379.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK VAR ANG ST 2X15MM,10354261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,843.00,252.90,358.27,716.55,,,,,,,,,,,,,service not payable,,,,,,,425.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,358.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,632.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,632.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,716.55,,,percent of total billed charges,,,387.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK VAR ANG ST 2X16MM,10354262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,968.00,290.40,375.58,822.80,,,,,,,,,,,,,,,,,,,,375.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,411.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,726.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.80,,,percent of total billed charges,,,435.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK VAR ANG ST 2X16MM,10354262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,968.00,290.40,411.40,822.80,,,,,,,,,,,,,service not payable,,,,,,,488.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,411.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,726.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,484.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,726.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,822.80,,,percent of total billed charges,,,445.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK STAR ST 2X18MM,10354263,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,843.00,252.90,327.08,716.55,,,,,,,,,,,,,,,,,,,,327.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,632.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,716.55,,,percent of total billed charges,,,379.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK STAR ST 2X18MM,10354263,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,843.00,252.90,358.27,716.55,,,,,,,,,,,,,service not payable,,,,,,,425.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,358.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,632.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,632.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,716.55,,,percent of total billed charges,,,387.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Allergen Region 9 Respiratory Panel (3001719),10354462,CDM,0300,RC,86003,CPT,,,,,,outpatient,facility,,,61.00,18.30,4.96,51.85,,22.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.12,,,fee schedule,,,16.54,,,fee schedule,,,10.88,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,10.81,,,fee schedule,,,4.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.22,,,fee schedule,,,11.80,,,fee schedule,,,,,,,,,5.12,,,fee schedule,,,,,,,,,6.73,,,fee schedule,,,10.65,,,fee schedule,,,45.75,,,percent of total billed charges,,,5.12,,,fee schedule,,,4.96,,,fee schedule,,,5.22,,,fee schedule,,,7.92,,,fee schedule,,,5.12,,,fee schedule,,,45.75,,,percent of total billed charges,,,,,,,,,5.22,,,fee schedule,,,,,,,,,51.85,,,percent of total billed charges,,,28.06,,,percent of total billed charges,,,,,,,,,5.74,,,fee schedule,,,5.12,,,fee schedule,,,,,,,,,5.06,,,fee schedule,,,5.12,,,fee schedule,,,,,,,,,5.16,,,fee schedule,,,,,,,,
Allergen Region 9 Respiratory Panel (3001719),10354462,CDM,0300,RC,86003,CPT,394,EAPG,,,,outpatient,facility,,,61.00,18.30,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WALKER CAM TD AIR STD MD,10354938,CDM,0274,RC,L4387,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM TD AIR STD MD,10354938,CDM,0274,RC,L4387,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,370.64,,,,,,,,161.38,,,fee schedule,,,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,339.48,,,fee schedule,,,142.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",164.61,,,fee schedule,,,370.64,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,334.56,,,fee schedule,,,123.0,,,percent of total billed charges,,,161.38,,,fee schedule,,,142.76,,,fee schedule,,,164.61,,,fee schedule,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,161.38,,,fee schedule,,,123.0,,,percent of total billed charges,,,142.76,,,fee schedule,,,164.61,,,fee schedule,,,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,
LENS INTEROCULAR 6X13MM 16.0,10354939,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2443.00,732.90,947.88,2076.55,,,,,,,,,,,,,,,,,,,,947.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1038.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1832.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1221.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2076.55,,,percent of total billed charges,,,1099.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTEROCULAR 6X13MM 16.0,10354939,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2443.00,732.90,1038.27,2076.55,,,,,,,,,,,,,service not payable,,,,,,,1232.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1038.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1832.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1221.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1832.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2076.55,,,percent of total billed charges,,,1123.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 6.0D 15.0,10354941,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 6.0D 15.0,10354941,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE ALLODERM 16X20 XT PERF X_1522320P X_ALLERGA,10354943,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,22174.00,6652.20,8603.51,18847.90,,10865.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9313.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8603.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9423.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16630.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11087.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18847.90,,,percent of total billed charges,,,9978.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE ALLODERM 16X20 XT PERF X_1522320P X_ALLERGA,10354943,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,22174.00,6652.20,9313.08,22174.0,,10865.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9313.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11184.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9423.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16630.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11087.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16630.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18847.90,,,percent of total billed charges,,,10200.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,22174.0,,,percent of total billed charges,,,,,,,,service not payable,22174.0,,,percent of total billed charges,,
TISSUE ALLODERM 16X20 XT PERF X_1522320P X_ALLERGA,10354943,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,22174.00,6652.20,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER CIRCULAR W/TRITECH X_TRIEEA28MT X_COVIDIEN,10354945,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3685.00,1105.50,1429.78,3132.25,,,,,,,,,,,,,,,,,,,,1429.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1566.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2763.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1842.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3132.25,,,percent of total billed charges,,,1658.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER CIRCULAR W/TRITECH X_TRIEEA28MT X_COVIDIEN,10354945,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3685.00,1105.50,1566.12,3132.25,,,,,,,,,,,,,service not payable,,,,,,,1858.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1566.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2763.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1842.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2763.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3132.25,,,percent of total billed charges,,,1695.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Culture Water Infection Control,10355,CDM,0300,RC,87071,CPT,,,,,,outpatient,facility,,,64.00,19.20,9.40,54.40,,40.13,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,9.69,,,fee schedule,,,29.94,,,fee schedule,,,20.62,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,20.47,,,fee schedule,,,9.40,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",9.88,,,fee schedule,,,22.35,,,fee schedule,,,,,,,,,9.69,,,fee schedule,,,,,,,,,12.64,,,fee schedule,,,20.18,,,fee schedule,,,48.0,,,percent of total billed charges,,,9.69,,,fee schedule,,,9.40,,,fee schedule,,,9.88,,,fee schedule,,,14.87,,,fee schedule,,,9.69,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,9.88,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,10.88,,,fee schedule,,,9.69,,,fee schedule,,,,,,,,,9.59,,,fee schedule,,,9.69,,,fee schedule,,,,,,,,,9.79,,,fee schedule,,,,,,,,
Culture Water Infection Control,10355,CDM,0300,RC,87071,CPT,396,EAPG,,,,outpatient,facility,,,64.00,19.20,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM SHOULDER COMP 17X55MM,10355010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM SHOULDER COMP 17X55MM,10355010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE POSITIONING HUM 13MM X_113581 X_BIOMET,10355011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE POSITIONING HUM 13MM X_113581 X_BIOMET,10355011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 10X122MM,10355012,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 10X122MM,10355012,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG BONE INTRAMEDULLARY MD 16,10355013,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG BONE INTRAMEDULLARY MD 16,10355013,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM DIS SIG POS SZ5 4MM R,10355014,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM DIS SIG POS SZ5 4MM R,10355014,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROSTHESIS 8MMX5CM,10355016,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10792.00,3237.60,4187.30,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4187.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9173.20,,,percent of total billed charges,,,4856.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROSTHESIS 8MMX5CM,10355016,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10792.00,3237.60,4532.64,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5443.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9173.20,,,percent of total billed charges,,,4964.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EDWARDS BALLOON CATHETER X_9350BC23A X_EDWARDS LIF,10355080,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EDWARDS BALLOON CATHETER X_9350BC23A X_EDWARDS LIF,10355080,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EDWARDS e-SHEATH INTRODUCER SET 16FR X_916ESA X_ED,10355081,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EDWARDS e-SHEATH INTRODUCER SET 16FR X_916ESA X_ED,10355081,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRIP PLT LG 200MM W/2.0 CBLE X_6704-3-093 X_STRYKE,10355082,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6060.00,1818.00,2351.28,5151.0,,2969.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2545.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2351.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2575.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4545.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3030.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5151.0,,,percent of total billed charges,,,2727.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRIP PLT LG 200MM W/2.0 CBLE X_6704-3-093 X_STRYKE,10355082,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6060.00,1818.00,2545.20,5151.0,,2969.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2545.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3056.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2575.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4545.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3030.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4545.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5151.0,,,percent of total billed charges,,,2787.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1 LEVEL 18MM OZARK X_AA01-41F18V X_STRYKER,10355083,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1 LEVEL 18MM OZARK X_AA01-41F18V X_STRYKER,10355083,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANT CERV ST FIXED 4X16MM,10355084,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANT CERV ST FIXED 4X16MM,10355084,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD YUKON CONTOURED 3.5X25MM,10355086,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD YUKON CONTOURED 3.5X25MM,10355086,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER BTRFLY 21.7MM,10355087,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,475.00,142.50,184.30,403.75,,,,,,,,,,,,,,,,,,,,184.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.75,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER BTRFLY 21.7MM,10355087,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,475.00,142.50,201.88,403.75,,,,,,,,,,,,,service not payable,,,,,,,239.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,201.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,237.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,356.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,403.75,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANT CERV ST 4.5X14MM X_8801-04514DA X_STRYKE,10355090,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANT CERV ST 4.5X14MM X_8801-04514DA X_STRYKE,10355090,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER BI-V SOLAR MRI CRT-P X_W1TR03 X_MEDTRONI,10355091,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,19044.00,5713.20,7389.07,16187.4,,9331.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7998.48,,,percent of total billed charges,,Paid in addition to inpatient services ,7389.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8093.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14283.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9522.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16187.4,,,percent of total billed charges,,,8569.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER BI-V SOLAR MRI CRT-P X_W1TR03 X_MEDTRONI,10355091,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,19044.00,5713.20,7998.48,16187.4,,9331.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7998.48,,,percent of total billed charges,,Paid in addition to outpatient services ,9605.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8093.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14283.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9522.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14283.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16187.4,,,percent of total billed charges,,,8760.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EDWARDS BALLOON CATHETER X_9350BC25A X_EDWARDS LIF,10355094,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4770.00,1431.00,1850.76,4054.5,,,,,,,,,,,,,,,,,,,,1850.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4054.5,,,percent of total billed charges,,,2146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EDWARDS BALLOON CATHETER X_9350BC25A X_EDWARDS LIF,10355094,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4770.00,1431.00,2027.25,4054.5,,,,,,,,,,,,,service not payable,,,,,,,2405.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4054.5,,,percent of total billed charges,,,2194.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB HIP G7 SZ F 36MM,10355189,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB HIP G7 SZ F 36MM,10355189,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 135D 13X145MM,10355190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 135D 13X145MM,10355190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM G7 ACETAB 36MM - 6MM,10355191,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1968.00,590.40,763.58,1672.8,,,,,,,,,,,,,,,,,,,,763.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1672.8,,,percent of total billed charges,,,885.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM G7 ACETAB 36MM - 6MM,10355191,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1968.00,590.40,836.40,1672.8,,,,,,,,,,,,,service not payable,,,,,,,992.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1672.8,,,percent of total billed charges,,,905.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA KNEE CEMENTED 29X8MM,10355192,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE CEMENTED 29X8MM,10355192,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ D RT,10355193,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ D RT,10355193,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE SRD RT SZ 6,10355194,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE SRD RT SZ 6,10355194,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART FEM VI R 6-9 CD 11MM,10355195,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART FEM VI R 6-9 CD 11MM,10355195,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ D 50MM,10355196,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ D 50MM,10355196,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB HIP G7 SZ D 36MM,10355197,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB HIP G7 SZ D 36MM,10355197,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 135D 14X150MM,10355198,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 135D 14X150MM,10355198,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT FEM ENDO II TAPER 3MM,10355199,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT FEM ENDO II TAPER 3MM,10355199,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ENDO II HIP 45MM,10355200,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ENDO II HIP 45MM,10355200,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM HIP ECHO FX 7.0MM,10355201,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4524.00,1357.20,1755.31,3845.40,,,,,,,,,,,,,,,,,,,,1755.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1922.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3845.40,,,percent of total billed charges,,,2035.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM HIP ECHO FX 7.0MM,10355201,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4524.00,1357.20,1922.7,3845.40,,,,,,,,,,,,,service not payable,,,,,,,2281.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1922.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3845.40,,,percent of total billed charges,,,2081.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SYS SUPERA 6F 60X6MM,10355203,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4770.00,1431.00,1850.76,4054.5,,,,,,,,,,,,,,,,,,,,1850.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4054.5,,,percent of total billed charges,,,2146.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SYS SUPERA 6F 60X6MM,10355203,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4770.00,1431.00,2027.25,4054.5,,,,,,,,,,,,,service not payable,,,,,,,2405.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2027.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4054.5,,,percent of total billed charges,,,2194.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE PEEK 9X28MM X_3303-20928M X_STRYKER,10355204,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PEEK 9X28MM X_3303-20928M X_STRYKER,10355204,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP WRIST FUSION SH BEND,10355205,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10192.00,3057.60,3954.50,8663.20,,4994.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4280.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3954.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4331.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7644.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5096.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8663.20,,,percent of total billed charges,,,4586.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP WRIST FUSION SH BEND,10355205,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10192.00,3057.60,4280.64,8663.20,,4994.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4280.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5140.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4331.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7644.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5096.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7644.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8663.20,,,percent of total billed charges,,,4688.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE ST T15 3.5X14MM,10355206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,252.00,75.60,97.78,214.20,,,,,,,,,,,,,,,,,,,,97.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,189.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.20,,,percent of total billed charges,,,113.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE ST T15 3.5X14MM,10355206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,252.00,75.60,107.10,214.20,,,,,,,,,,,,,service not payable,,,,,,,127.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,107.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,189.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,126.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,189.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,214.20,,,percent of total billed charges,,,115.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 4.0X24MM X_AR-8940-24 X_ARTHREX INC,10355207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 4.0X24MM X_AR-8940-24 X_ARTHREX INC,10355207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Opiates Scr Rflx to Quant Urine,10355651,CDM,0300,RC,80307,CPT,,,,,,outpatient,facility,,,71.00,21.30,32.66,140.44,,43.88,,,percent of total billed charges,,,60.90,,,fee schedule,,,34.93,,,fee schedule,,,129.59,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,128.63,,,fee schedule,,,59.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",62.12,,,fee schedule,,,140.44,,,fee schedule,,,,,,,,,60.90,,,fee schedule,,,,,,,,,80.04,,,fee schedule,,,126.77,,,fee schedule,,,53.25,,,percent of total billed charges,,,60.90,,,fee schedule,,,59.03,,,fee schedule,,,62.12,,,fee schedule,,,94.13,,,fee schedule,,,60.90,,,fee schedule,,,53.25,,,percent of total billed charges,,,,,,,,,62.12,,,fee schedule,,,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,68.35,,,fee schedule,,,60.90,,,fee schedule,,,,,,,,,60.28,,,fee schedule,,,60.90,,,fee schedule,,,,,,,,,61.5,,,fee schedule,,,,,,,,
Opiates Scr Rflx to Quant Urine,10355651,CDM,0300,RC,80307,CPT,2041,EAPG,,,,outpatient,facility,,,71.00,21.30,71.0,141.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,120.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,71.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,71.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WALKER CAM TD AIR STD LG,10355942,CDM,0274,RC,L4387,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM TD AIR STD LG,10355942,CDM,0274,RC,L4387,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,370.64,,,,,,,,161.38,,,fee schedule,,,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,339.48,,,fee schedule,,,142.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",164.61,,,fee schedule,,,370.64,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,334.56,,,fee schedule,,,123.0,,,percent of total billed charges,,,161.38,,,fee schedule,,,142.76,,,fee schedule,,,164.61,,,fee schedule,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,161.38,,,fee schedule,,,123.0,,,percent of total billed charges,,,142.76,,,fee schedule,,,164.61,,,fee schedule,,,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,
NAIL SUPRACONDYLAR 12X340MM X_1826-1234S X_STRYKER,10355943,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5416.00,1624.80,2101.41,4603.60,,2653.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2274.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2101.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4062.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2708.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4603.60,,,percent of total billed charges,,,2437.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SUPRACONDYLAR 12X340MM X_1826-1234S X_STRYKER,10355943,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5416.00,1624.80,2274.72,4603.60,,2653.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2274.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2731.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4062.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2708.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4062.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4603.60,,,percent of total billed charges,,,2491.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TLIF II IMP ALEUT 10X32X10MM 7DEG X_3303-21032M X_,10355944,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TLIF II IMP ALEUT 10X32X10MM 7DEG X_3303-21032M X_,10355944,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP PL 8H 3.5X194MM RT,10355945,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8770.00,2631.00,3402.76,7454.5,,4297.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3683.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3402.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3727.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7454.5,,,percent of total billed charges,,,3946.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP PL 8H 3.5X194MM RT,10355945,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8770.00,2631.00,3683.40,7454.5,,4297.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3683.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4423.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3727.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7454.5,,,percent of total billed charges,,,4034.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/3 5H 61MM,10355947,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,391.00,117.30,151.71,332.35,,,,,,,,,,,,,,,,,,,,151.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,293.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,195.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.35,,,percent of total billed charges,,,175.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/3 5H 61MM,10355947,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,391.00,117.30,166.17,332.35,,,,,,,,,,,,,service not payable,,,,,,,197.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,166.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,293.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,195.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,293.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,332.35,,,percent of total billed charges,,,179.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT MINI 3.5X28MM,10355948,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT MINI 3.5X28MM,10355948,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH METACROSS 6X40MM 135CM,10355949,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,385.63,,,percent of total billed charges,,,,,,,,service not payable,304.51,,,percent of total billed charges,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH METACROSS 5X80MM 135CM,10355950,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,385.63,,,percent of total billed charges,,,,,,,,service not payable,304.51,,,percent of total billed charges,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 TAPER SZ11,10355952,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 TAPER SZ11,10355952,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STRUCT STRATOSPHERE CP 13MM X_436013B X_MEDTRONIC,10355953,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,29176.00,8752.80,11320.29,24799.60,,14296.24,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12253.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11320.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12399.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21882.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14588.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24799.60,,,percent of total billed charges,,,13129.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STRUCT STRATOSPHERE CP 13MM X_436013B X_MEDTRONIC,10355953,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,29176.00,8752.80,12253.92,24799.60,,14296.24,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12253.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14716.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12399.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21882.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14588.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21882.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24799.60,,,percent of total billed charges,,,13420.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FIXED ANG SELFDRILL 4X12MM X_3120412 X_MEDTR,10355954,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FIXED ANG SELFDRILL 4X12MM X_3120412 X_MEDTR,10355954,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT DX SWVLK 3.5X13.5MM,10355956,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT DX SWVLK 3.5X13.5MM,10355956,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 110X10.5MM,10356687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2486.00,745.80,964.57,2113.10,,,,,,,,,,,,,,,,,,,,964.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2113.10,,,percent of total billed charges,,,1118.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 110X10.5MM,10356687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,,,,,,,,,,,,service not payable,,,,,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX 12/14 44 12MM,10356689,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX 12/14 44 12MM,10356689,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ALTRX LD 10D 40X58 4MM,10356690,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ALTRX LD 10D 40X58 4MM,10356690,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT X3 TRIATHLON CS 3 12MM,10356691,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT X3 TRIATHLON CS 3 12MM,10356691,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLER CIRCULAR W/TRITECH X_TRIEEA31 X_COVIDIEN,10356692,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3685.00,1105.50,1429.78,3132.25,,,,,,,,,,,,,,,,,,,,1429.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1566.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2763.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1842.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3132.25,,,percent of total billed charges,,,1658.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER CIRCULAR W/TRITECH X_TRIEEA31 X_COVIDIEN,10356692,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3685.00,1105.50,1566.12,3132.25,,,,,,,,,,,,,service not payable,,,,,,,1858.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1566.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2763.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1842.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2763.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3132.25,,,percent of total billed charges,,,1695.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL JOURNEY SZ4 X_71422434 X_SMITH NEPHEW,10356693,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4284.00,1285.20,1662.19,3641.40,,,,,,,,,,,,,,,,,,,,1662.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3641.40,,,percent of total billed charges,,,1927.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL JOURNEY SZ4 X_71422434 X_SMITH NEPHEW,10356693,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4284.00,1285.20,1820.7,3641.40,,,,,,,,,,,,,service not payable,,,,,,,2160.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3641.40,,,percent of total billed charges,,,1970.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETABULAR 58MM F X_702-11-58F X_STRYKER ORT,10356694,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR 58MM F X_702-11-58F X_STRYKER ORT,10356694,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ2 12MM X_5531-G-212-E X_STRYKER OR,10356695,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ2 12MM X_5531-G-212-E X_STRYKER OR,10356695,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LK T8 2.0X16MM,10356696,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1231.00,369.30,477.63,1046.35,,,,,,,,,,,,,,,,,,,,477.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1046.35,,,percent of total billed charges,,,553.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LK T8 2.0X16MM,10356696,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1231.00,369.30,523.17,1046.35,,,,,,,,,,,,,service not payable,,,,,,,620.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,923.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,923.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1046.35,,,percent of total billed charges,,,566.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE ANT TLIF 9X14X30 X_5294308 X_NUVASIVE,10356697,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE ANT TLIF 9X14X30 X_5294308 X_NUVASIVE,10356697,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST SALINE HP 600ML,10356698,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST SALINE HP 600ML,10356698,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE ALLODERM CTR M PERF 1.3,10356699,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,14130.00,4239.00,5482.44,12010.5,,6923.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5934.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5482.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6005.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10597.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7065.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12010.5,,,percent of total billed charges,,,6358.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE ALLODERM CTR M PERF 1.3,10356699,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,14130.00,4239.00,5934.60,14130.0,,6923.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5934.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7127.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6005.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10597.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7065.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10597.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12010.5,,,percent of total billed charges,,,6499.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,14130.0,,,percent of total billed charges,,,,,,,,service not payable,14130.0,,,percent of total billed charges,,
TISSUE ALLODERM CTR M PERF 1.3,10356699,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,14130.00,4239.00,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TRHEADED 400MM X_102314 X_SMITH NEPHEW,10356700,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,433.00,129.90,168.00,368.05,,,,,,,,,,,,,,,,,,,,168.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,324.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.05,,,percent of total billed charges,,,194.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TRHEADED 400MM X_102314 X_SMITH NEPHEW,10356700,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,433.00,129.90,184.03,368.05,,,,,,,,,,,,,service not payable,,,,,,,218.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,184.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,324.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,216.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,324.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,368.05,,,percent of total billed charges,,,199.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE 18X14X14MM,10356702,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5127.00,1538.10,1989.28,4357.95,,2512.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2153.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1989.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2178.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3845.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2563.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4357.95,,,percent of total billed charges,,,2307.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE 18X14X14MM,10356702,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5127.00,1538.10,2153.34,4357.95,,2512.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2153.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2586.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2178.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3845.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2563.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3845.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4357.95,,,percent of total billed charges,,,2358.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE 20X20X20MM X_EZXP20-20-20 X_STRYKER ORTHOPA,10356703,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6209.00,1862.70,2409.09,5277.65,,3042.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2607.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2409.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2638.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4656.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3104.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5277.65,,,percent of total billed charges,,,2794.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE 20X20X20MM X_EZXP20-20-20 X_STRYKER ORTHOPA,10356703,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6209.00,1862.70,2607.78,5277.65,,3042.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2607.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3131.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2638.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4656.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3104.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4656.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5277.65,,,percent of total billed charges,,,2856.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PL DIS FIB 3H L 59MM X_7282-1003 X_SMITH NEP,10356885,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2408.00,722.40,934.30,2046.8,,,,,,,,,,,,,,,,,,,,934.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1023.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1806.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1204.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046.8,,,percent of total billed charges,,,1083.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PL DIS FIB 3H L 59MM X_7282-1003 X_SMITH NEP,10356885,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2408.00,722.40,1023.4,2046.8,,,,,,,,,,,,,service not payable,,,,,,,1214.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1023.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1806.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1204.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1806.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2046.8,,,percent of total billed charges,,,1107.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST HP 550-590CC,10356887,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST HP 550-590CC,10356887,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM G7 ACETAB 36MM - 3MM,10356891,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM G7 ACETAB 36MM - 3MM,10356891,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ E 52MM,10356892,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2788.00,836.40,1081.74,2369.80,,,,,,,,,,,,,,,,,,,,1081.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1184.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2091.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1394.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2369.80,,,percent of total billed charges,,,1254.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ E 52MM,10356892,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2788.00,836.40,1184.90,2369.80,,,,,,,,,,,,,service not payable,,,,,,,1406.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1184.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2091.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1394.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2091.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2369.80,,,percent of total billed charges,,,1282.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ E 36MM,10356893,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ E 36MM,10356893,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ D 40MM,10356894,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ D 40MM,10356894,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ G 58MM,10356895,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ G 58MM,10356895,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC PPS SZ 10,10356896,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC PPS SZ 10,10356896,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC PPS SZ 11,10356897,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC PPS SZ 11,10356897,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD SLEEVE FEM TI TYPE1 40MM,10356898,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7360.00,2208.00,2855.68,6256.0,,3606.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3091.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2855.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5520.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6256.0,,,percent of total billed charges,,,3312.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD SLEEVE FEM TI TYPE1 40MM,10356898,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7360.00,2208.00,3091.20,6256.0,,3606.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3091.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3712.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3128.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5520.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5520.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6256.0,,,percent of total billed charges,,,3385.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TI TYPE1 6MM,10356899,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TI TYPE1 6MM,10356899,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHNBX 9MMX79MMX135CM,10356900,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,11861.00,3558.30,5040.93,10081.85,,7330.10,,,percent of total billed charges,,,,,,,,service not payable,5788.17,,,percent of total billed charges,,,5982.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5040.93,,,percent of total billed charges,,,,,,,,,8895.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5930.5,,,percent of total billed charges,,,,,,,,service not payable,8895.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10081.85,,,percent of total billed charges,,,5456.06,,,percent of total billed charges,,,,,,,,,7709.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,7709.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD LT SZ 11,10357061,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD LT SZ 11,10357061,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ G LT,10357063,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ G LT,10357063,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR LT 10-12 10MM,10357065,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR LT 10-12 10MM,10357065,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST SALINE HP 700ML,10357067,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST SALINE HP 700ML,10357067,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER FIDUCIAL COBRA 0.8X3.5,10357069,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,1101.00,330.30,427.19,935.85,,,,,,,,,,,,,,,,,,,,427.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,825.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,550.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,,495.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER FIDUCIAL COBRA 0.8X3.5,10357069,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,1101.00,330.30,467.93,935.85,,,,,,,,,,,,,service not payable,,,,,,,555.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,467.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,825.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,550.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,825.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,935.85,,,percent of total billed charges,,,506.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ENDOFLIP NASAL TIP 16CM,10357071,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1956.00,586.80,831.30,1662.60,,1208.81,,,percent of total billed charges,,,,,,,,service not payable,954.53,,,percent of total billed charges,,,986.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,831.30,,,percent of total billed charges,,,,,,,,,1467.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,978.0,,,percent of total billed charges,,,,,,,,service not payable,1467.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,,899.76,,,percent of total billed charges,,,,,,,,,1271.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1271.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ENDOFLIP NASAL TIP 8CM X_EF-325N X_GIVEN IMAG,10357072,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1956.00,586.80,831.30,1662.60,,1208.81,,,percent of total billed charges,,,,,,,,service not payable,954.53,,,percent of total billed charges,,,986.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,831.30,,,percent of total billed charges,,,,,,,,,1467.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,978.0,,,percent of total billed charges,,,,,,,,service not payable,1467.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,,899.76,,,percent of total billed charges,,,,,,,,,1271.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1271.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ENDOFLIP NASAL TIP 20CM X_ES-320 X_GIVEN IMAG,10357073,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1629.00,488.70,692.33,1384.65,,1006.72,,,percent of total billed charges,,,,,,,,service not payable,794.95,,,percent of total billed charges,,,821.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,692.33,,,percent of total billed charges,,,,,,,,,1221.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,814.5,,,percent of total billed charges,,,,,,,,service not payable,1221.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1384.65,,,percent of total billed charges,,,749.34,,,percent of total billed charges,,,,,,,,,1058.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1058.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ENDOFLIP NASAL TIP 30CM X_ES-330 X_GIVEN IMAG,10357074,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1956.00,586.80,831.30,1662.60,,1208.81,,,percent of total billed charges,,,,,,,,service not payable,954.53,,,percent of total billed charges,,,986.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,831.30,,,percent of total billed charges,,,,,,,,,1467.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,978.0,,,percent of total billed charges,,,,,,,,service not payable,1467.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,,899.76,,,percent of total billed charges,,,,,,,,,1271.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1271.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH FOLEY LUBRI-SIL 12F 5CC,10357075,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,143.00,42.90,60.77,121.55,,88.37,,,percent of total billed charges,,,,,,,,service not payable,69.78,,,percent of total billed charges,,,72.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,,,service not payable,107.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Level 1 in Field - Trauma Level,10357310,CDM,0683,RC,G0390,HCPCS,,,,,,outpatient,facility,,,2966.00,889.80,1260.55,2521.10,,1832.99,,,percent of total billed charges,,,,,,,,,1447.41,,,percent of total billed charges,,,1496.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1260.55,,,percent of total billed charges,,,,,,,,,2224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1483.0,,,percent of total billed charges,,,,,,,,,2224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2521.10,,,percent of total billed charges,,,1364.36,,,percent of total billed charges,,,,,,,,,1927.90,,,percent of total billed charges,,,,,,,,,,,,,,,1927.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
Level 1 in Field - Trauma Level,10357310,CDM,0683,RC,G0390,HCPCS,05045,APC,,,,outpatient,facility,,,2966.00,889.80,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Level 1 in Field - Trauma Level,10357310,CDM,0683,RC,G0390,HCPCS,852,EAPG,,,,outpatient,facility,,,2966.00,889.80,254.45,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,254.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW SERRATO 4.5X45MM X_482614545 X_STRYKER SPINE,10357541,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO 4.5X45MM X_482614545 X_STRYKER SPINE,10357541,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK CAGE SPACER 10X25X4DEG X_48485104 X_STRYKER S,10357542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK CAGE SPACER 10X25X4DEG X_48485104 X_STRYKER S,10357542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ 3 11MM,10357543,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ 3 11MM,10357543,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP TI 3.5X46MM,10357544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP TI 3.5X46MM,10357544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NAT 125D 10MMX38CM,10357563,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NAT 125D 10MMX38CM,10357563,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 100X10.5MM,10357564,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2486.00,745.80,964.57,2113.10,,,,,,,,,,,,,,,,,,,,964.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2113.10,,,percent of total billed charges,,,1118.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 100X10.5MM,10357564,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,,,,,,,,,,,,service not payable,,,,,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR SZ3-4 13MM X_71453148 X_SMITH NEP,10357565,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR SZ3-4 13MM X_71453148 X_SMITH NEP,10357565,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DESTINATION 6F 119CM,10357566,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1650.00,495.00,701.25,1402.5,,1019.7,,,percent of total billed charges,,,,,,,,service not payable,805.20,,,percent of total billed charges,,,832.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,1237.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,825.0,,,percent of total billed charges,,,,,,,,service not payable,1237.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1402.5,,,percent of total billed charges,,,759.0,,,percent of total billed charges,,,,,,,,,1072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATHETER PERITONEAL EXT X_8888111132 X_MEDTRON,10357567,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,2410.00,723.00,1024.25,2048.5,,1489.38,,,percent of total billed charges,,,,,,,,service not payable,1176.08,,,percent of total billed charges,,,1215.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,,,,,,,1807.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1205.0,,,percent of total billed charges,,,,,,,,service not payable,1807.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2048.5,,,percent of total billed charges,,,1108.60,,,percent of total billed charges,,,,,,,,,1566.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1566.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT HELIX 30MM X_7800130 X_NUVASIVE,10357568,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2417.00,725.10,937.80,2054.45,,,,,,,,,,,,,,,,,,,,937.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1812.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1208.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2054.45,,,percent of total billed charges,,,1087.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT HELIX 30MM X_7800130 X_NUVASIVE,10357568,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2417.00,725.10,1027.22,2054.45,,,,,,,,,,,,,service not payable,,,,,,,1219.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1027.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1812.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1208.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1812.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2054.45,,,percent of total billed charges,,,1111.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL INTRAMEDULLARY 7MMX26CM,10357569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4410.00,1323.00,1711.08,3748.5,,,,,,,,,,,,,,,,,,,,1711.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1874.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3748.5,,,percent of total billed charges,,,1984.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL INTRAMEDULLARY 7MMX26CM,10357569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4410.00,1323.00,1874.25,3748.5,,,,,,,,,,,,,service not payable,,,,,,,2224.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1874.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3748.5,,,percent of total billed charges,,,2028.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW END CAP FLUSH IMPING,10357570,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW END CAP FLUSH IMPING,10357570,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC STARDRIVE 4.8X38MM,10357571,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC STARDRIVE 4.8X38MM,10357571,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC STARDRIVE 4.8X42MM,10357572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC STARDRIVE 4.8X42MM,10357572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT STARDRIVE 3.5X24MM,10357573,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,271.00,81.30,105.15,230.35,,,,,,,,,,,,,,,,,,,,105.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,203.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,135.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.35,,,percent of total billed charges,,,121.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT STARDRIVE 3.5X24MM,10357573,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,271.00,81.30,115.18,230.35,,,,,,,,,,,,,service not payable,,,,,,,136.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,115.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,203.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,135.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,203.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,230.35,,,percent of total billed charges,,,124.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE BALL NOSE 2.2MM 28IN,10357576,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,885.00,265.50,376.13,752.25,,546.93,,,percent of total billed charges,,,,,,,,service not payable,431.88,,,percent of total billed charges,,,446.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,376.13,,,percent of total billed charges,,,,,,,,,663.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,442.5,,,percent of total billed charges,,,,,,,,service not payable,663.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,752.25,,,percent of total billed charges,,,407.10,,,percent of total billed charges,,,,,,,,,575.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,575.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE BALL NOSE 2X700MM,10357577,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,675.47,,,percent of total billed charges,,,,,,,,service not payable,533.38,,,percent of total billed charges,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,710.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,710.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NAIL FEM 10.5X105MM,10357579,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NAIL FEM 10.5X105MM,10357579,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM TFN RT 130D 400X10MM,10357580,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM TFN RT 130D 400X10MM,10357580,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK 5X60MM,10357581,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1784.00,535.20,692.19,1516.40,,,,,,,,,,,,,,,,,,,,692.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1516.40,,,percent of total billed charges,,,802.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK 5X60MM,10357581,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1784.00,535.20,758.20,1516.40,,,,,,,,,,,,,service not payable,,,,,,,899.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1516.40,,,percent of total billed charges,,,820.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK TI 5X40MM,10357582,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1784.00,535.20,692.19,1516.40,,,,,,,,,,,,,,,,,,,,692.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1516.40,,,percent of total billed charges,,,802.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK TI 5X40MM,10357582,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1784.00,535.20,758.20,1516.40,,,,,,,,,,,,,service not payable,,,,,,,899.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1516.40,,,percent of total billed charges,,,820.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE SS HEADED 48MM,10357583,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,359.00,107.70,139.29,305.15,,,,,,,,,,,,,,,,,,,,139.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,269.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,305.15,,,percent of total billed charges,,,161.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE SS HEADED 48MM,10357583,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,359.00,107.70,152.57,305.15,,,,,,,,,,,,,service not payable,,,,,,,181.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,152.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,269.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,179.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,269.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,305.15,,,percent of total billed charges,,,165.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FIXED RT 8-11 EF 14MM,10357584,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,359.00,107.70,139.29,305.15,,,,,,,,,,,,,,,,,,,,139.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,269.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,305.15,,,percent of total billed charges,,,161.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FIXED RT 8-11 EF 14MM,10357584,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,359.00,107.70,152.57,305.15,,,,,,,,,,,,,service not payable,,,,,,,181.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,152.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,269.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,179.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,269.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,305.15,,,percent of total billed charges,,,165.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NARROW RT SZ 9.0,10357585,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15261.00,4578.30,5921.27,12971.85,,7477.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6409.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5921.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6485.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11445.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7630.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12971.85,,,percent of total billed charges,,,6867.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NARROW RT SZ 9.0,10357585,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15261.00,4578.30,6409.62,12971.85,,7477.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6409.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7697.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6485.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11445.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7630.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11445.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12971.85,,,percent of total billed charges,,,7020.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIAL 2 PEG RT SZ E,10357586,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6852.00,2055.60,2658.58,5824.20,,3357.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2877.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2658.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5139.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3426.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5824.20,,,percent of total billed charges,,,3083.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIAL 2 PEG RT SZ E,10357586,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6852.00,2055.60,2877.84,5824.20,,3357.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2877.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3456.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5139.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3426.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5139.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5824.20,,,percent of total billed charges,,,3151.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA NEXGEN 10X35MM,10357587,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA NEXGEN 10X35MM,10357587,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP SZ 8 8X34.3X136MM,10357588,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP SZ 8 8X34.3X136MM,10357588,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB E1 SZ D 36MM,10357589,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB E1 SZ D 36MM,10357589,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HIP DOME G7 LP 6.5X20MM,10357590,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,165.00,49.50,64.02,140.25,,,,,,,,,,,,,,,,,,,,64.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HIP DOME G7 LP 6.5X20MM,10357590,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.12,140.25,,,,,,,,,,,,,service not payable,,,,,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB G7 SZ D MH 50MM,10357591,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17431.00,5229.30,6763.23,14816.35,,8541.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7321.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6763.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7408.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13073.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8715.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14816.35,,,percent of total billed charges,,,7843.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB G7 SZ D MH 50MM,10357591,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17431.00,5229.30,7321.02,14816.35,,8541.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7321.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8792.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7408.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13073.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8715.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13073.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14816.35,,,percent of total billed charges,,,8018.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 7.50,10357592,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 7.50,10357592,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 26,10357593,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 26,10357593,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 26.5,10357594,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 26.5,10357594,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 28.5,10357595,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 28.5,10357595,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 22.5,10357596,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 22.5,10357596,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 25.5,10357597,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 25.5,10357597,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 26.0,10357598,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 26.0,10357598,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 27.0,10357599,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 27.0,10357599,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 28.0,10357600,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 28.0,10357600,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 300D 10.0,10357601,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 300D 10.0,10357601,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 17,10357602,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 17,10357602,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 25,10357603,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 25,10357603,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 25.5,10357604,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 25.5,10357604,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 26.5,10357605,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 26.5,10357605,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 28.0,10357606,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 28.0,10357606,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.00D 29.5,10357607,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.00D 29.5,10357607,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75D 9.5,10357608,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75D 9.5,10357608,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75D 23.5,10357609,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75D 23.5,10357609,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE SAVARY GILLIARD WIRE,10357610,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXP ENDOPROSTHESIS X_BXA062901A X_GORE MEDIC,10358055,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10845.00,3253.50,4207.86,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4207.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9218.25,,,percent of total billed charges,,,4880.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXP ENDOPROSTHESIS X_BXA062901A X_GORE MEDIC,10358055,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10845.00,3253.50,4554.90,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5470.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9218.25,,,percent of total billed charges,,,4988.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT EXP ENDOPROSTHESIS X_BXA063901A X_GORE MEDIC,10358056,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10845.00,3253.50,4207.86,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4207.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9218.25,,,percent of total billed charges,,,4880.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT EXP ENDOPROSTHESIS X_BXA063901A X_GORE MEDIC,10358056,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10845.00,3253.50,4554.90,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5470.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9218.25,,,percent of total billed charges,,,4988.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT FIRM HERNIA 10X16CM X_1016002P X_ALLERGAN IN,10358057,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,13068.00,3920.40,5070.38,11107.80,,6403.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5488.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5070.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5553.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9801.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6534.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11107.80,,,percent of total billed charges,,,5880.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FIRM HERNIA 10X16CM X_1016002P X_ALLERGAN IN,10358057,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,13068.00,3920.40,5488.56,11107.80,,6403.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5488.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6591.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5553.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9801.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6534.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9801.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11107.80,,,percent of total billed charges,,,6011.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE GUIDED EPI-SENSE 3CM,10358060,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26226.00,7867.80,10175.69,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10175.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22292.10,,,percent of total billed charges,,,11801.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE GUIDED EPI-SENSE 3CM,10358060,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26226.00,7867.80,11014.92,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13228.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22292.10,,,percent of total billed charges,,,12063.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PRO2 ATRICLIP 35MM,10358061,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,12295.00,3688.50,4770.46,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4770.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10450.75,,,percent of total billed charges,,,5532.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PRO2 ATRICLIP 35MM,10358061,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,12295.00,3688.50,5163.90,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6201.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10450.75,,,percent of total billed charges,,,5655.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PRO2 ATRICLIP 40MM,10358062,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,12295.00,3688.50,4770.46,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4770.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10450.75,,,percent of total billed charges,,,5532.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PRO2 ATRICLIP 40MM,10358062,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,12295.00,3688.50,5163.90,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6201.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10450.75,,,percent of total billed charges,,,5655.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PRO2 ATRICLIP 45MM,10358063,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,12295.00,3688.50,4770.46,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4770.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10450.75,,,percent of total billed charges,,,5532.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PRO2 ATRICLIP 45MM,10358063,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,12295.00,3688.50,5163.90,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6201.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10450.75,,,percent of total billed charges,,,5655.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PRO2 ATRICLIP 50MM,10358064,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,12295.00,3688.50,4770.46,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4770.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10450.75,,,percent of total billed charges,,,5532.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PRO2 ATRICLIP 50MM,10358064,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,12295.00,3688.50,5163.90,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6201.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10450.75,,,percent of total billed charges,,,5655.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATRICLIP SYS EXCLSN PROV  35MM X_A000971 X_ATRICUR,10358065,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATRICLIP SYS EXCLSN PROV  35MM X_A000971 X_ATRICUR,10358065,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PROV ATRICLIP 40MM,10358066,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PROV ATRICLIP 40MM,10358066,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PROV ATRICLIP 45MM,10358067,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PROV ATRICLIP 45MM,10358067,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN PROV ATRICLIP 50MM,10358068,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN PROV ATRICLIP 50MM,10358068,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB TC3 RP SZ2.5 10MM,10358069,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9844.00,2953.20,3819.47,8367.40,,4823.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4134.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3819.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4183.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7383.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4922.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8367.40,,,percent of total billed charges,,,4429.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB TC3 RP SZ2.5 10MM,10358069,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9844.00,2953.20,4134.48,8367.40,,4823.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4134.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4965.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4183.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7383.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4922.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7383.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8367.40,,,percent of total billed charges,,,4528.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANG 2.3X16MM LCKG VAR X_30-2316 X_ACUMED,10358071,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,689.00,206.70,267.33,585.65,,,,,,,,,,,,,,,,,,,,267.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.65,,,percent of total billed charges,,,310.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANG 2.3X16MM LCKG VAR X_30-2316 X_ACUMED,10358071,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,689.00,206.70,292.82,585.65,,,,,,,,,,,,,service not payable,,,,,,,347.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,516.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,585.65,,,percent of total billed charges,,,316.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VAR LK ANG 2.3X20MM,10358072,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,689.00,206.70,267.33,585.65,,,,,,,,,,,,,,,,,,,,267.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.65,,,percent of total billed charges,,,310.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VAR LK ANG 2.3X20MM,10358072,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,689.00,206.70,292.82,585.65,,,,,,,,,,,,,service not payable,,,,,,,347.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,516.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,585.65,,,percent of total billed charges,,,316.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VAR LK ANG 2.3X22MM,10358073,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,689.00,206.70,267.33,585.65,,,,,,,,,,,,,,,,,,,,267.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.65,,,percent of total billed charges,,,310.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VAR LK ANG 2.3X22MM,10358073,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,689.00,206.70,292.82,585.65,,,,,,,,,,,,,service not payable,,,,,,,347.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,292.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,516.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,344.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,516.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,585.65,,,percent of total billed charges,,,316.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 2 LVL 40MM,10358074,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 2 LVL 40MM,10358074,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SOFTSILK 7.0X25MM X_7207002 X_SMITH NEPHEW,10358076,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1064.00,319.20,412.83,904.40,,,,,,,,,,,,,,,,,,,,412.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,798.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,532.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,904.40,,,percent of total billed charges,,,478.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SOFTSILK 7.0X25MM X_7207002 X_SMITH NEPHEW,10358076,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1064.00,319.20,452.20,904.40,,,,,,,,,,,,,service not payable,,,,,,,536.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,452.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,798.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,532.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,798.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,904.40,,,percent of total billed charges,,,489.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE HI-TORQUE 0.035INX300CM,10358161,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.23,558.45,,406.03,,,percent of total billed charges,,,,,,,,service not payable,320.62,,,percent of total billed charges,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.23,,,percent of total billed charges,,,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,427.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE FEED MIC-KEY LP 18F 30CM,10358162,CDM,0272,RC,B4087,HCPCS,,,,,,outpatient,facility,,,1836.00,550.80,37.03,1560.60,,1134.65,,,percent of total billed charges,,,,,,,,service not payable,895.97,,,percent of total billed charges,,,926.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,918.0,,,fee schedule,,,37.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,918.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,780.30,,,percent of total billed charges,,,,,,,,,1377.0,,,percent of total billed charges,,,,,,,,service not payable,37.03,,,fee schedule,,,,,,,,,918.0,,,percent of total billed charges,,,,,,,,service not payable,1377.0,,,percent of total billed charges,,,37.03,,,fee schedule,,,826.20,,,fee schedule,,,,,,,,,1560.60,,,percent of total billed charges,,,844.56,,,percent of total billed charges,,,,,,,,,1193.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1193.40,,,percent of total billed charges,,,918.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
TUBE FEED MIC-KEY LP 18F 30CM,10358162,CDM,0272,RC,B4087,HCPCS,498,EAPG,,,,outpatient,facility,,,1836.00,550.80,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TUBE FEEDING NASOINTESTINAL 8F 109CM X_20-7438 X_H,10358200,CDM,0272,RC,B4082,HCPCS,,,,,,outpatient,facility,,,121.00,36.30,15.29,102.85,,74.78,,,percent of total billed charges,,,,,,,,service not payable,59.05,,,percent of total billed charges,,,61.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,60.5,,,fee schedule,,,15.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,60.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,51.42,,,percent of total billed charges,,,,,,,,,90.75,,,percent of total billed charges,,,,,,,,service not payable,15.29,,,fee schedule,,,,,,,,,60.5,,,percent of total billed charges,,,,,,,,service not payable,90.75,,,percent of total billed charges,,,15.29,,,fee schedule,,,54.45,,,fee schedule,,,,,,,,,102.85,,,percent of total billed charges,,,55.66,,,percent of total billed charges,,,,,,,,,78.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,78.65,,,percent of total billed charges,,,60.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
TUBE FEEDING NASOINTESTINAL 8F 109CM X_20-7438 X_H,10358200,CDM,0272,RC,B4082,HCPCS,498,EAPG,,,,outpatient,facility,,,121.00,36.30,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CIRCAID JUX ANKLE FT CUST,10358201,CDM,0272,RC,A6545,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,269.01,,101.97,,,percent of total billed charges,,,117.13,,,fee schedule,,,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,246.39,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,269.01,,,fee schedule,,,,,,,,,117.13,,,fee schedule,,,,,,,,,70.13,,,percent of total billed charges,,,242.82,,,fee schedule,,,123.75,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,82.5,,,percent of total billed charges,,,117.13,,,fee schedule,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,119.47,,,fee schedule,,,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,107.25,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,118.3,,,fee schedule,,,,,,,,
CIRCAID JUX L LEG HD LONG M X_33034017 X_MEDI USA,10358202,CDM,0270,RC,A6545,HCPCS,,,,,,outpatient,facility,,,318.00,95.40,117.13,270.30,,196.52,,,percent of total billed charges,,,117.13,,,fee schedule,,,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,246.39,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,269.01,,,fee schedule,,,,,,,,,117.13,,,fee schedule,,,,,,,,,135.15,,,percent of total billed charges,,,242.82,,,fee schedule,,,238.5,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,159.0,,,percent of total billed charges,,,117.13,,,fee schedule,,,238.5,,,percent of total billed charges,,,,,,,,service not payable,119.47,,,fee schedule,,,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,206.70,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,118.3,,,fee schedule,,,,,,,,
SCREW HEADED 3X12MM X_IC3012 X_STRYKER ORTHOPAEDIC,10358210,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1554.00,466.20,602.95,1320.90,,,,,,,,,,,,,,,,,,,,602.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1165.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,777.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1320.90,,,percent of total billed charges,,,699.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADED 3X12MM X_IC3012 X_STRYKER ORTHOPAEDIC,10358210,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1554.00,466.20,660.45,1320.90,,,,,,,,,,,,,service not payable,,,,,,,783.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,660.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1165.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,777.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1165.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1320.90,,,percent of total billed charges,,,714.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 8X270MM X_1830-0827S X_STRYKER ORTHOP,10358211,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4118.00,1235.40,1597.78,3500.30,,,,,,,,,,,,,,,,,,,,1597.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1750.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3088.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2059.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3500.30,,,percent of total billed charges,,,1853.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 8X270MM X_1830-0827S X_STRYKER ORTHOP,10358211,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4118.00,1235.40,1750.15,3500.30,,,,,,,,,,,,,service not payable,,,,,,,2077.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1750.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3088.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2059.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3088.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3500.30,,,percent of total billed charges,,,1894.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE STND RT 10H XSHRT X_54-25783 X_STRYKER ORTHO,10358212,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3283.00,984.90,1273.80,2790.55,,,,,,,,,,,,,,,,,,,,1273.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2790.55,,,percent of total billed charges,,,1477.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE STND RT 10H XSHRT X_54-25783 X_STRYKER ORTHO,10358212,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3283.00,984.90,1395.27,2790.55,,,,,,,,,,,,,service not payable,,,,,,,1655.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1395.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2462.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1641.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2462.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2790.55,,,percent of total billed charges,,,1510.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEAK CAGE 9X25X4DEG X_48485094 X_STRYKER SP,10358213,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEAK CAGE 9X25X4DEG X_48485094 X_STRYKER SP,10358213,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT FIBROBLAST SKIN 37.55CM,10358214,CDM,0278,RC,Q4186,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FIBROBLAST SKIN 37.55CM,10358214,CDM,0278,RC,Q4186,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT FIBROBLAST SKIN 37.55CM,10358214,CDM,0278,RC,Q4186,HCPCS,2010,EAPG,,,,outpatient,facility,,,4099.00,1229.70,127.78,158.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,127.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.33,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,158.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NUSHIELD AMNION/CHORION 2X3CM,10358215,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NUSHIELD AMNION/CHORION 2X3CM,10358215,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NUSHIELD AMNION/CHORION 2X3CM,10358215,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,3279.00,983.70,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE METAL 10X29MM,10358216,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE METAL 10X29MM,10358216,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MSP Exam,10358751,CDM,0761,RC,32550,CPT,,,,,,outpatient,facility,,,7499.00,2249.70,118.0,6374.15,,4634.38,,,percent of total billed charges,,,,,,,,,3659.51,,,percent of total billed charges,,,3782.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3187.07,,,percent of total billed charges,,,,,,,,,5624.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3749.5,,,percent of total billed charges,,,,,,,,,5624.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6374.15,,,percent of total billed charges,,,3449.54,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MSP Exam,10358751,CDM,0761,RC,32550,CPT,05341,APC,,,,outpatient,facility,,,7499.00,2249.70,3246.12,7772.77,,,,,,,,3384.25,,,fee schedule,,,,,,,,,,,,,,,7119.31,,,fee schedule,,,3246.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3451.93,,,fee schedule,,,7772.77,,,fee schedule,,,,,,,,,3384.25,,,fee schedule,,,,,,,,,,,,,,,7016.13,,,fee schedule,,,,,,,,,3384.25,,,fee schedule,,,3246.12,,,fee schedule,,,3451.93,,,fee schedule,,,,,,,,,3384.25,,,fee schedule,,,,,,,,,3246.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3451.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3384.25,,,fee schedule,,,,,,,,,,,,,,,3384.25,,,fee schedule,,,,,,,,,3417.95,,,fee schedule,,,,,,,,
MSP Exam,10358751,CDM,0761,RC,32550,CPT,68,EAPG,,,,outpatient,facility,,,7499.00,2249.70,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PET Exam,10358759,CDM,0404,RC,78815,CPT,,,,,,outpatient,facility,,,7810.00,2343.00,1990.0,6638.5,,2505.91,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE Paid in addition to outpatient services",,,,,,,1990.0,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE Paid in addition to outpatient services",3939.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3319.25,,,percent of total billed charges,,,,,,,,,5857.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3905.0,,,percent of total billed charges,,,,,,,,,5857.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6638.5,,,percent of total billed charges,,,3592.60,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PET Exam,10358759,CDM,0404,RC,78815,CPT,05594,APC,,,,outpatient,facility,,,7810.00,2343.00,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
PET Exam,10358759,CDM,0404,RC,78815,CPT,290,EAPG,,,,outpatient,facility,,,7810.00,2343.00,1941.11,5004.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5004.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4254.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1941.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1941.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1941.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2974.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3272.24,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COMP FEM NAR LEFT SZ 7,10358781,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR LEFT SZ 7,10358781,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ D LEFT,10358783,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ D LEFT,10358783,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA KNEE CEMENTED 35X9MM,10358785,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE CEMENTED 35X9MM,10358785,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART FEM PS L 6-9 CD 10MM,10358787,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART FEM PS L 6-9 CD 10MM,10358787,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM HIP ARCOS REV 15X50MM,10358789,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10885.00,3265.50,4223.38,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4223.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9252.25,,,percent of total billed charges,,,4898.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM HIP ARCOS REV 15X50MM,10358789,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10885.00,3265.50,4571.70,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5490.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9252.25,,,percent of total billed charges,,,5007.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM HIP ACROS REV SZ C,10358790,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21112.00,6333.60,8191.46,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8191.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17945.20,,,percent of total billed charges,,,9500.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM HIP ACROS REV SZ C,10358790,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21112.00,6333.60,8867.04,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10648.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17945.20,,,percent of total billed charges,,,9711.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB FB CRUCIATE SZ9,10358791,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB FB CRUCIATE SZ9,10358791,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON FLASH OSTIAL 4X8,10358793,CDM,0278,RC,C1726,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON FLASH OSTIAL 4X8,10358793,CDM,0278,RC,C1726,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON FLASH OSTIAL 7X12,10358795,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,2229.13,,,percent of total billed charges,,,,,,,,service not payable,1760.22,,,percent of total billed charges,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2344.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOGRAFT MAIN BODY 1_Endologix Inc_BEA22-80/L16-4,10358797,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,31687.00,9506.10,12294.56,26933.95,,15526.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13308.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12294.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13466.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26933.95,,,percent of total billed charges,,,14259.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOGRAFT MAIN BODY 1_Endologix Inc_BEA22-80/L16-4,10358797,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,31687.00,9506.10,13308.54,26933.95,,15526.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13308.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15982.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13466.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26933.95,,,percent of total billed charges,,,14576.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROX VELA 28X75 X_A28-28/C75 V X_ENDOLOGIX I,10358798,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,18028.00,5408.40,6994.86,15323.80,,8833.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7571.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6994.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7661.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13521.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9014.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15323.80,,,percent of total billed charges,,,8112.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROX VELA 28X75 X_A28-28/C75 V X_ENDOLOGIX I,10358798,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,18028.00,5408.40,7571.76,15323.80,,8833.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7571.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9093.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7661.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13521.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9014.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13521.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15323.80,,,percent of total billed charges,,,8292.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER BONE SCREW SS CN 4.5X10 X_71143110 X_SMITH,10358799,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,154.00,46.20,59.75,130.90,,,,,,,,,,,,,,,,,,,,59.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.90,,,percent of total billed charges,,,69.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER BONE SCREW SS CN 4.5X10 X_71143110 X_SMITH,10358799,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,154.00,46.20,65.45,130.90,,,,,,,,,,,,,service not payable,,,,,,,77.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,65.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,115.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,77.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,130.90,,,percent of total billed charges,,,70.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS MAL PENILE 9.5MM,10358800,CDM,0278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,25122.00,7536.60,9747.34,21353.70,,12309.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10551.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9747.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10676.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21353.70,,,percent of total billed charges,,,11304.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS MAL PENILE 9.5MM,10358800,CDM,0278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,25122.00,7536.60,10551.24,21353.70,,12309.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10551.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12671.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10676.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,21353.70,,,percent of total billed charges,,,11556.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS MAL PENILE 11MM,10358801,CDM,0278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,25122.00,7536.60,9747.34,21353.70,,12309.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10551.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9747.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10676.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21353.70,,,percent of total billed charges,,,11304.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS MAL PENILE 11MM,10358801,CDM,0278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,25122.00,7536.60,10551.24,21353.70,,12309.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10551.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12671.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10676.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,21353.70,,,percent of total billed charges,,,11556.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS MAL PENILE 13MM,10358802,CDM,0278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,25122.00,7536.60,9747.34,21353.70,,12309.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10551.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9747.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10676.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21353.70,,,percent of total billed charges,,,11304.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS MAL PENILE 13MM,10358802,CDM,0278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,25122.00,7536.60,10551.24,21353.70,,12309.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10551.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12671.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10676.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,21353.70,,,percent of total billed charges,,,11556.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRO CHKFLO 16F X_G09582 X_COOK MEDICAL IN,10359084,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,553.00,165.90,235.03,470.05,,341.75,,,percent of total billed charges,,,,,,,,service not payable,269.86,,,percent of total billed charges,,,278.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,235.03,,,percent of total billed charges,,,,,,,,,414.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,service not payable,414.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,470.05,,,percent of total billed charges,,,254.38,,,percent of total billed charges,,,,,,,,,359.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,359.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TRACH LF 20MMX5CM X_G08553 X_COOK MEDICAL IN,10359085,CDM,0278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,3356.00,1006.80,1302.13,2852.60,,,,,,,,,,,,,,,,,,,,1302.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1426.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2517.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1678.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2852.60,,,percent of total billed charges,,,1510.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TRACH LF 20MMX5CM X_G08553 X_COOK MEDICAL IN,10359085,CDM,0278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,3356.00,1006.80,1426.3,2852.60,,,,,,,,,,,,,service not payable,,,,,,,1692.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1426.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2517.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1678.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2517.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2852.60,,,percent of total billed charges,,,1543.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR LEFT SZ 6,10359086,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12145.00,3643.50,4712.26,10323.25,,5951.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5100.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4712.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5161.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9108.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6072.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10323.25,,,percent of total billed charges,,,5465.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR LEFT SZ 6,10359086,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12145.00,3643.50,5100.90,10323.25,,5951.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5100.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6125.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5161.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6072.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10323.25,,,percent of total billed charges,,,5586.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ C LEFT,10359088,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5295.00,1588.50,2054.46,4500.75,,2594.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2223.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2054.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2250.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3971.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2647.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.75,,,percent of total billed charges,,,2382.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ C LEFT,10359088,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5295.00,1588.50,2223.90,4500.75,,2594.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2223.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2670.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2250.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3971.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2647.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3971.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4500.75,,,percent of total billed charges,,,2435.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA KNEE CEMENTED 32X8.5MM,10359090,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3306.00,991.80,1282.73,2810.10,,,,,,,,,,,,,,,,,,,,1282.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1405.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2479.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1653.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2810.10,,,percent of total billed charges,,,1487.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE CEMENTED 32X8.5MM,10359090,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3306.00,991.80,1405.05,2810.10,,,,,,,,,,,,,service not payable,,,,,,,1667.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1405.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2479.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1653.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2479.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2810.10,,,percent of total billed charges,,,1520.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE LT 6-9 CD 13MM,10359092,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3893.00,1167.90,1510.48,3309.05,,,,,,,,,,,,,,,,,,,,1510.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2919.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1946.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3309.05,,,percent of total billed charges,,,1751.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE LT 6-9 CD 13MM,10359092,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3893.00,1167.90,1654.52,3309.05,,,,,,,,,,,,,service not payable,,,,,,,1963.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1654.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2919.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1946.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2919.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3309.05,,,percent of total billed charges,,,1790.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM REDAPT SZ17 240MM X_71354706 X_SMITH NEPHEW,10359093,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24792.00,7437.60,9619.30,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9619.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21073.20,,,percent of total billed charges,,,11156.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REDAPT SZ17 240MM X_71354706 X_SMITH NEPHEW,10359093,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24792.00,7437.60,10412.64,21073.20,,12148.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10412.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12505.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10536.6,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18594.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18594.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21073.20,,,percent of total billed charges,,,11404.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE ANCHOR PEEK 7X12X14 4DEG X_48321074 X_STRYKER,10359094,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE ANCHOR PEEK 7X12X14 4DEG X_48321074 X_STRYKER,10359094,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SELF-DRILL ANCHOR 3.5X12 X_48335312 X_STRYKE,10359095,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SELF-DRILL ANCHOR 3.5X12 X_48335312 X_STRYKE,10359095,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS UV TORIC ASPHERIC 10.5D,10359096,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS UV TORIC ASPHERIC 10.5D,10359096,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 650CC,10359099,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 650CC,10359099,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 650CC,10359100,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 650CC,10359100,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 750CC,10359101,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 750CC,10359101,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 SZ4 11MM,10359227,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 SZ4 11MM,10359227,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL CR X3 SZ4 22MM X_5537-G-422 X_STRYKE,10359228,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL CR X3 SZ4 22MM X_5537-G-422 X_STRYKE,10359228,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT F-D 15MM SZ4 LT,10359229,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3903.00,1170.90,1514.36,3317.55,,,,,,,,,,,,,,,,,,,,1514.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2927.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1951.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.55,,,percent of total billed charges,,,1756.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT F-D 15MM SZ4 LT,10359229,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3903.00,1170.90,1658.77,3317.55,,,,,,,,,,,,,service not payable,,,,,,,1968.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1658.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2927.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1951.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2927.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3317.55,,,percent of total billed charges,,,1795.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH WAVELINQ 4F X_W04200 X_CR BARD INC,10359230,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,22948.00,6884.40,9752.90,19505.80,,14181.86,,,percent of total billed charges,,,,,,,,service not payable,11198.62,,,percent of total billed charges,,,11574.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11474.0,,,percent of total billed charges,,,,,,,,service not payable,17211.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19505.80,,,percent of total billed charges,,,10556.08,,,percent of total billed charges,,,,,,,,,14916.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,14916.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SLIM Y 2 SHAFT HOLES T8,10359672,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3972.00,1191.60,1541.14,3376.20,,,,,,,,,,,,,,,,,,,,1541.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1688.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2979.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1986.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3376.20,,,percent of total billed charges,,,1787.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SLIM Y 2 SHAFT HOLES T8,10359672,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3972.00,1191.60,1688.10,3376.20,,,,,,,,,,,,,service not payable,,,,,,,2003.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1688.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2979.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1986.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2979.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3376.20,,,percent of total billed charges,,,1827.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LIFESTREAM 80CM 9X58MM,10359674,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8032.00,2409.60,3116.42,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3116.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.20,,,percent of total billed charges,,,3614.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LIFESTREAM 80CM 9X58MM,10359674,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8032.00,2409.60,3373.44,6827.20,,3935.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3373.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4051.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6024.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4016.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6024.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6827.20,,,percent of total billed charges,,,3694.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 8/36MM NON-F X_BE 6698 X_INHEALT,10359777,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 8/55MM NON-F X_BE 6699 X_INHEALT,10359778,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 9/36MM NON-F X_BE 6700 X_INHEALT,10359779,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE LARYNGECTOMY 9/55MM NON-F,10359780,CDM,0272,RC,A7520,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DIAGNOSTIC 4F 145D 110C,10359781,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,42.5,,30.90,,,percent of total billed charges,,,,,,,,service not payable,24.40,,,percent of total billed charges,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21.25,,,percent of total billed charges,,,,,,,,,37.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25.0,,,percent of total billed charges,,,,,,,,service not payable,37.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,32.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,32.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DIAGNOSTIC 4F 100C,10359782,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,50.00,15.00,21.25,42.5,,30.90,,,percent of total billed charges,,,,,,,,service not payable,24.40,,,percent of total billed charges,,,25.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21.25,,,percent of total billed charges,,,,,,,,,37.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25.0,,,percent of total billed charges,,,,,,,,service not payable,37.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,42.5,,,percent of total billed charges,,,23.0,,,percent of total billed charges,,,,,,,,,32.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,32.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 12X14MMX9MM X_48806094 X_STRYKER,10359784,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 12X14MMX9MM X_48806094 X_STRYKER,10359784,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM COLLARED HIGH SZ 12,10359787,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7705.00,2311.50,2989.54,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2989.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6549.25,,,percent of total billed charges,,,3467.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM COLLARED HIGH SZ 12,10359787,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7705.00,2311.50,3236.10,6549.25,,3775.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3236.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3886.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3274.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5778.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5778.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6549.25,,,percent of total billed charges,,,3544.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART BCS XPLE SZ5-6 LT,10360076,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS XPLE SZ5-6 LT,10360076,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II LT SZ6,10360077,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II LT SZ6,10360077,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM D8.0,10360078,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM D8.0,10360078,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CIRCAID JUX HD LONG L LEG LG,10360079,CDM,0272,RC,A6545,HCPCS,,,,,,outpatient,facility,,,318.00,95.40,117.13,270.30,,196.52,,,percent of total billed charges,,,117.13,,,fee schedule,,,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,246.39,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,269.01,,,fee schedule,,,,,,,,,117.13,,,fee schedule,,,,,,,,,135.15,,,percent of total billed charges,,,242.82,,,fee schedule,,,238.5,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,159.0,,,percent of total billed charges,,,117.13,,,fee schedule,,,238.5,,,percent of total billed charges,,,,,,,,service not payable,119.47,,,fee schedule,,,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,206.70,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,118.3,,,fee schedule,,,,,,,,
GRAFT BONE DBM BOAT SHORT 5CM,10360080,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE DBM BOAT SHORT 5CM,10360080,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM BOAT SHORT 5CM,10360080,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,4426.00,1327.80,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBE JONES FROST W/HOLE 5.5X16 X_11100-5516 X_GUNT,10360083,CDM,0278,RC,A4263,HCPCS,,,,,,inpatient,facility,,,525.00,157.50,203.70,446.25,,,,,,,,,,,,,,,,,,,,203.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBE JONES FROST W/HOLE 5.5X16 X_11100-5516 X_GUNT,10360083,CDM,0278,RC,A4263,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.12,446.25,,,,,,,,,,,,,service not payable,,,,,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE JONES FROST W/HOLE 4.5X17 X_11100-4517 X_GUNT,10360084,CDM,0278,RC,A4263,HCPCS,,,,,,inpatient,facility,,,525.00,157.50,203.70,446.25,,,,,,,,,,,,,,,,,,,,203.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBE JONES FROST W/HOLE 4.5X17 X_11100-4517 X_GUNT,10360084,CDM,0278,RC,A4263,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.12,446.25,,,,,,,,,,,,,service not payable,,,,,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE JONES FROST W/HOLE 5.0X17 X_11100-5017 X_GUNT,10360085,CDM,0278,RC,A4263,HCPCS,,,,,,inpatient,facility,,,525.00,157.50,203.70,446.25,,,,,,,,,,,,,,,,,,,,203.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBE JONES FROST W/HOLE 5.0X17 X_11100-5017 X_GUNT,10360085,CDM,0278,RC,A4263,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.12,446.25,,,,,,,,,,,,,service not payable,,,,,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TUBE JONES FROST W/HOLE 5.5X17 X_11100-5517 X_GUNT,10360086,CDM,0278,RC,A4263,HCPCS,,,,,,inpatient,facility,,,525.00,157.50,203.70,446.25,,,,,,,,,,,,,,,,,,,,203.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBE JONES FROST W/HOLE 5.5X17 X_11100-5517 X_GUNT,10360086,CDM,0278,RC,A4263,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.12,446.25,,,,,,,,,,,,,service not payable,,,,,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 700CC,10360087,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 700CC,10360087,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF DIOPTER 11.5,10360091,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF DIOPTER 11.5,10360091,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI FL TD 7X75MM,10360092,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1124.00,337.20,436.11,955.40,,,,,,,,,,,,,,,,,,,,436.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,955.40,,,percent of total billed charges,,,505.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI FL TD 7X75MM,10360092,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1124.00,337.20,477.70,955.40,,,,,,,,,,,,,service not payable,,,,,,,566.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,955.40,,,percent of total billed charges,,,517.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE GLDNG VEGA PS 12MM X_NX221 X_AESCULAP IMPL,10360093,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE GLDNG VEGA PS 12MM X_NX221 X_AESCULAP IMPL,10360093,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ4 12MM X_5531-G-412-E X_STRYKER OR,10360094,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ4 12MM X_5531-G-412-E X_STRYKER OR,10360094,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANT CERV SS FIXED 4X14MM,10360096,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANT CERV SS FIXED 4X14MM,10360096,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE AMINO FIX 2X3CM X_ASP-5230 X_MIMEDX,10360098,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3322.00,996.60,1288.94,2823.70,,,,,,,,,,,,,,,,,,,,1288.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1411.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1661.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2823.70,,,percent of total billed charges,,,1494.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE AMINO FIX 2X3CM X_ASP-5230 X_MIMEDX,10360098,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3322.00,996.60,1411.85,2823.70,,,,,,,,,,,,,service not payable,,,,,,,1675.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1411.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2491.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1661.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2491.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2823.70,,,percent of total billed charges,,,1528.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH PINN DEST 6FR 45CM,10360099,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,446.00,133.80,189.55,379.10,,275.63,,,percent of total billed charges,,,,,,,,service not payable,217.65,,,percent of total billed charges,,,224.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,,,,,,,334.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,223.0,,,percent of total billed charges,,,,,,,,service not payable,334.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,379.10,,,percent of total billed charges,,,205.16,,,percent of total billed charges,,,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ASAHI GS 300CM,10360100,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF TI 8X11X30MM,10360101,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF TI 8X11X30MM,10360101,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOGRAFT MAIN BODY AFX2 X_BEA 25-80/I20-40 X_ENDO,10360102,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,31687.00,9506.10,12294.56,26933.95,,15526.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13308.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12294.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13466.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26933.95,,,percent of total billed charges,,,14259.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOGRAFT MAIN BODY AFX2 X_BEA 25-80/I20-40 X_ENDO,10360102,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,31687.00,9506.10,13308.54,26933.95,,15526.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13308.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15982.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13466.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26933.95,,,percent of total billed charges,,,14576.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR RT SZ 3-4 9MM,10360103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR RT SZ 3-4 9MM,10360103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEMORAL DIS LT SZ4 5MM X_5540-A-402 X_STRY,10360104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3544.00,1063.20,1375.07,3012.40,,,,,,,,,,,,,,,,,,,,1375.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3012.40,,,percent of total billed charges,,,1594.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEMORAL DIS LT SZ4 5MM X_5540-A-402 X_STRY,10360104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3544.00,1063.20,1506.2,3012.40,,,,,,,,,,,,,service not payable,,,,,,,1787.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3012.40,,,percent of total billed charges,,,1630.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID 25D MED AUG LEFT,10360105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12247.00,3674.10,4751.84,10409.95,,6001.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5143.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4751.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5204.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10409.95,,,percent of total billed charges,,,5511.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID 25D MED AUG LEFT,10360105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12247.00,3674.10,5143.74,10409.95,,6001.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5143.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6177.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5204.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10409.95,,,percent of total billed charges,,,5633.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PARIETAL RT FRONTAL,10360106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,27865.00,8359.50,10811.62,23685.25,,13653.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11703.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10811.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11842.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20898.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13932.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23685.25,,,percent of total billed charges,,,12539.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PARIETAL RT FRONTAL,10360106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,27865.00,8359.50,11703.30,23685.25,,13653.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11703.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14055.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11842.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20898.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13932.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20898.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,23685.25,,,percent of total billed charges,,,12817.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 11X11X30 8DEG X_5211308 X_NUVASIV,10360107,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 11X11X30 8DEG X_5211308 X_NUVASIV,10360107,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10360230,CDM,0360,RC,33990,CPT,,,,,,outpatient,facility,,,7103.00,2130.90,315.44,7856.0,,7103.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,3582.75,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,315.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,5327.25,,,percent of total billed charges,,,,,,,,service not payable,315.44,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,5327.25,,,percent of total billed charges,,,315.44,,,fee schedule,,,,,,,,service not payable,,,,,,,6037.55,,,percent of total billed charges,,,3267.38,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10360230,CDM,0360,RC,33990,CPT,3060,EAPG,,,,outpatient,facility,,,7103.00,2130.90,7103.0,83927.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83927.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,71338.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,57974.96,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,63772.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10360231,CDM,0360,RC,33993,CPT,,,,,,outpatient,facility,,,1652.00,495.60,158.34,7856.0,,1652.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,833.27,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,158.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,1239.0,,,percent of total billed charges,,,,,,,,service not payable,158.34,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,1239.0,,,percent of total billed charges,,,158.34,,,fee schedule,,,,,,,,service not payable,,,,,,,1404.2,,,percent of total billed charges,,,759.92,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10360231,CDM,0360,RC,33993,CPT,87,EAPG,,,,outpatient,facility,,,1652.00,495.60,1652.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1652.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1652.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1652.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10360232,CDM,0360,RC,33992,CPT,,,,,,outpatient,facility,,,1869.00,560.70,195.63,7856.0,,1869.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,942.72,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,1401.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,1401.75,,,percent of total billed charges,,,195.63,,,fee schedule,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,,859.74,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10360232,CDM,0360,RC,33992,CPT,87,EAPG,,,,outpatient,facility,,,1869.00,560.70,1869.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1869.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1869.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1869.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT X3 TRIATHLON CS 3 10MM X_5531-G-310-E X_STR,10360635,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT X3 TRIATHLON CS 3 10MM X_5531-G-310-E X_STR,10360635,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FIBULOCK 3.8X130MM RIGHT,10360637,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FIBULOCK 3.8X130MM RIGHT,10360637,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM GLBL ADV 52X21,10360979,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM GLBL ADV 52X21,10360979,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE PIN 3.2X300MM X_71111000 X_SMITH NEPHEW,10360980,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,149.00,44.70,57.81,126.65,,,,,,,,,,,,,,,,,,,,57.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.65,,,percent of total billed charges,,,67.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDE PIN 3.2X300MM X_71111000 X_SMITH NEPHEW,10360980,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,149.00,44.70,63.32,126.65,,,,,,,,,,,,,service not payable,,,,,,,75.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,63.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 5.5X50MM,10360981,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 5.5X50MM,10360981,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM VESUVIUS 5CC,10360982,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,3016.00,904.80,1170.21,2563.60,,,,,,,,,,,,,,,,,,,,1170.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1281.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2262.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2563.60,,,percent of total billed charges,,,1357.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE DBM VESUVIUS 5CC,10360982,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,3016.00,904.80,1281.8,2563.60,,,,,,,,,,,,,service not payable,,,,,,,1521.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1281.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2262.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2262.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2563.60,,,percent of total billed charges,,,1387.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM VESUVIUS 5CC,10360982,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,3016.00,904.80,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL EMBOL RUBY POD 14MMX60CM,10360983,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2368.95,4737.90,,3444.73,,,percent of total billed charges,,,,,,,,service not payable,2720.11,,,percent of total billed charges,,,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3623.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ACCOLADE SR MRI,10360984,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,14392.00,4317.60,5584.10,12233.20,,7052.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6044.64,,,percent of total billed charges,,Paid in addition to inpatient services ,5584.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6116.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10794.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12233.20,,,percent of total billed charges,,,6476.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ACCOLADE SR MRI,10360984,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,14392.00,4317.60,6044.64,12233.20,,7052.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6044.64,,,percent of total billed charges,,Paid in addition to outpatient services ,7259.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6116.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10794.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10794.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12233.20,,,percent of total billed charges,,,6620.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE ANT TLIF VBR 12X14X40 12,10360985,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE ANT TLIF VBR 12X14X40 12,10360985,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 5 12MM,10360986,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 5 12MM,10360986,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE DIST FEM AUG SZ 5 12MM,10360987,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE DIST FEM AUG SZ 5 12MM,10360987,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB PRESSFIT STR 14X110MM,10360988,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB PRESSFIT STR 14X110MM,10360988,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE POS FEM AUG SZ 5 8MM,10360989,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE POS FEM AUG SZ 5 8MM,10360989,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE DIST FEM AUG SZ 5 4MM,10360990,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE DIST FEM AUG SZ 5 4MM,10360990,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS RP INSRT SZ 5 20MM,10360991,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS RP INSRT SZ 5 20MM,10360991,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT LIFE 130X7X30,10360992,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2514.00,754.20,975.43,2136.90,,,,,,,,,,,,,,,,,,,,975.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2136.90,,,percent of total billed charges,,,1131.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT LIFE 130X7X30,10360992,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2514.00,754.20,1068.45,2136.90,,,,,,,,,,,,,service not payable,,,,,,,1268.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1068.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1885.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1257.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1885.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2136.90,,,percent of total billed charges,,,1156.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II RT SZ 8,10360993,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II RT SZ 8,10360993,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB ART BCS SZ 5-6 RT,10360994,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB ART BCS SZ 5-6 RT,10360994,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING HUMERUS 36MM STANDARD,10360995,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING HUMERUS 36MM STANDARD,10360995,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY HUMERUS STANDARD,10360996,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY HUMERUS STANDARD,10360996,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 560ML X_SSX-560 X_ALLERGA,10360999,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 560ML X_SSX-560 X_ALLERGA,10360999,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 400CC,10361000,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 400CC,10361000,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 420CC,10361001,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 420CC,10361001,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 445CC,10361002,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 445CC,10361002,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 470CC,10361003,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 470CC,10361003,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWIVELK DBL LD 5.5X22MM,10361004,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWIVELK DBL LD 5.5X22MM,10361004,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE SLIM Y 5 SHAFT HOLES T8,10361005,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3972.00,1191.60,1541.14,3376.20,,,,,,,,,,,,,,,,,,,,1541.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1688.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2979.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1986.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3376.20,,,percent of total billed charges,,,1787.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE SLIM Y 5 SHAFT HOLES T8,10361005,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3972.00,1191.60,1688.10,3376.20,,,,,,,,,,,,,service not payable,,,,,,,2003.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1688.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2979.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1986.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2979.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3376.20,,,percent of total billed charges,,,1827.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE O-TOE SZ5 BLK X_3511AD-SZ5BL X_JULIU,10361006,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,30.36,186.15,,135.34,,,percent of total billed charges,,,,,,,,service not payable,106.87,,,percent of total billed charges,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,,,,,,,service not payable,164.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,142.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 180CC,10361016,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 180CC,10361016,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 215CC,10361017,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 215CC,10361017,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 250CC,10361018,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 250CC,10361018,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 290CC,10361019,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 290CC,10361019,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 330CC,10361020,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 330CC,10361020,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 380CC,10361021,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 380CC,10361021,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 430CC,10361022,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 430CC,10361022,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST TALL HGT HP 485CC,10361023,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST TALL HGT HP 485CC,10361023,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST MD HGT HP 165CC,10361024,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST MD HGT HP 165CC,10361024,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST MD HGT HP 195CC,10361025,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST MD HGT HP 195CC,10361025,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST MD HGT HP 225CC,10361026,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST MD HGT HP 225CC,10361026,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST MD HGT HP 260CC,10361027,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST MD HGT HP 260CC,10361027,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 225CC,10361028,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6819.00,2045.70,2645.77,5796.15,,3341.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2863.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2645.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2898.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5114.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3409.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5796.15,,,percent of total billed charges,,,3068.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 225CC,10361028,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6819.00,2045.70,2863.98,5796.15,,3341.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2863.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3439.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2898.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5114.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3409.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5114.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5796.15,,,percent of total billed charges,,,3136.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST ARTOURA 500CC,10361029,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6819.00,2045.70,2645.77,5796.15,,3341.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2863.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2645.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2898.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5114.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3409.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5796.15,,,percent of total billed charges,,,3068.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST ARTOURA 500CC,10361029,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6819.00,2045.70,2863.98,5796.15,,3341.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2863.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3439.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2898.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5114.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3409.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5114.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5796.15,,,percent of total billed charges,,,3136.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT H UNI SZ1 7MM LM/RL,10361031,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT H UNI SZ1 7MM LM/RL,10361031,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM HP UNI SZ1 LM/RL,10361032,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM HP UNI SZ1 LM/RL,10361032,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB HP UNI SZ1 LM/RL,10361033,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB HP UNI SZ1 LM/RL,10361033,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD SELECT SECURE 3830 74CM X_3830-74 X_MEDTRONIC,10361034,CDM,0278,RC,C1779,HCPCS,,,,,,inpatient,facility,,,2223.00,666.90,862.52,1889.55,,,,,,,,,,,,,,,,,,,,862.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,944.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1889.55,,,percent of total billed charges,,,1000.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD SELECT SECURE 3830 74CM X_3830-74 X_MEDTRONIC,10361034,CDM,0278,RC,C1779,HCPCS,,,,,,outpatient,facility,,,2223.00,666.90,944.77,1889.55,,,,,,,,,,,,,service not payable,,,,,,,1121.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,944.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1667.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1667.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1889.55,,,percent of total billed charges,,,1022.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Allergen Region 9 Respiratory Panel IgE (3001719),10361282,CDM,0300,RC,82785,CPT,,,,,,outpatient,facility,,,10.00,3.00,4.60,34.33,,10.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,9.80,,,fee schedule,,,10.0,,,fee schedule,,,34.33,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,20.70,,,fee schedule,,,10.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.0,,,fee schedule,,,22.60,,,fee schedule,,,,,,,,,9.80,,,fee schedule,,,,,,,,,21.06,,,fee schedule,,,20.40,,,fee schedule,,,7.5,,,percent of total billed charges,,,9.80,,,fee schedule,,,10.0,,,fee schedule,,,10.0,,,fee schedule,,,24.77,,,fee schedule,,,9.80,,,fee schedule,,,7.5,,,percent of total billed charges,,,,,,,,,10.0,,,fee schedule,,,,,,,,,8.5,,,percent of total billed charges,,,4.60,,,percent of total billed charges,,,,,,,,,18.11,,,fee schedule,,,9.80,,,fee schedule,,,,,,,,,15.97,,,fee schedule,,,9.80,,,fee schedule,,,,,,,,,9.80,,,fee schedule,,,,,,,,
Allergen Region 9 Respiratory Panel IgE (3001719),10361282,CDM,0300,RC,82785,CPT,400,EAPG,,,,outpatient,facility,,,10.00,3.00,10.0,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PACEMAKER BIVENTRIC CRT-D DF-1,10361863,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,36475.00,10942.50,14152.30,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,14152.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31003.75,,,percent of total billed charges,,,16413.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER BIVENTRIC CRT-D DF-1,10361863,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,36475.00,10942.50,15319.5,31003.75,,17872.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,18397.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15501.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18237.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27356.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31003.75,,,percent of total billed charges,,,16778.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN DRILL HEADLESS 3.2X75MM,10361864,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1775.00,532.50,688.70,1508.75,,,,,,,,,,,,,,,,,,,,688.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1331.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,887.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,,798.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN DRILL HEADLESS 3.2X75MM,10361864,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1775.00,532.50,754.38,1508.75,,,,,,,,,,,,,service not payable,,,,,,,895.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1331.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,887.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1331.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,,816.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON MINI ONE 14FX1.7CM X_MI-5-1417 X_APPLIED ME,10361868,CDM,0272,RC,B4088,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,193.11,419.05,,304.67,,,percent of total billed charges,,,,,,,,service not payable,240.58,,,percent of total billed charges,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,246.5,,,fee schedule,,,193.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,246.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,193.11,,,fee schedule,,,,,,,,,246.5,,,percent of total billed charges,,,,,,,,service not payable,369.75,,,percent of total billed charges,,,193.11,,,fee schedule,,,221.85,,,fee schedule,,,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,320.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,320.45,,,percent of total billed charges,,,246.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
BUTTON MINI ONE 14FX1.7CM X_MI-5-1417 X_APPLIED ME,10361868,CDM,0272,RC,B4088,HCPCS,498,EAPG,,,,outpatient,facility,,,493.00,147.90,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BASE TIB REV ROTATING CEM SZ8,10361871,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17663.00,5298.90,6853.24,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6853.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15013.55,,,percent of total billed charges,,,7948.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB REV ROTATING CEM SZ8,10361871,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17663.00,5298.90,7418.46,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8909.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15013.55,,,percent of total billed charges,,,8124.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS FEMORAL RT SZ 8 CEM,10361873,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEMORAL RT SZ 8 CEM,10361873,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACE 66MM 3H X_71335566 X_SMITH NEPHEW,10361875,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3427.00,1028.10,1329.68,2912.95,,,,,,,,,,,,,,,,,,,,1329.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.95,,,percent of total billed charges,,,1542.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACE 66MM 3H X_71335566 X_SMITH NEPHEW,10361875,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3427.00,1028.10,1456.47,2912.95,,,,,,,,,,,,,service not payable,,,,,,,1728.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.95,,,percent of total billed charges,,,1576.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIBERTAK DISPOSABLES CRVD KIT,10361877,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIBERTAK DISPOSABLES CRVD KIT,10361877,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ RESTOR 2.5D 15.5D,10361878,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ RESTOR 2.5D 15.5D,10361878,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 520CC,10361881,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 520CC,10361881,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 560CC,10361882,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 560CC,10361882,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 525CC,10361883,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 525CC,10361883,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 545CC,10361884,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 545CC,10361884,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 580CC,10361885,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 580CC,10361885,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 615CC,10361886,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 615CC,10361886,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLGRFT 3X3CM,10361887,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3360.00,1008.00,1303.68,2856.0,,,,,,,,,,,,,,,,,,,,1303.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2520.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2856.0,,,percent of total billed charges,,,1512.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLGRFT 3X3CM,10361887,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3360.00,1008.00,1428.0,2856.0,,,,,,,,,,,,,service not payable,,,,,,,1694.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2520.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2520.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2856.0,,,percent of total billed charges,,,1545.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT PL AMNIOFILL 1000 MG,10361888,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT PL AMNIOFILL 1000 MG,10361888,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT PL AMNIOFILL 1000 MG,10361888,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,6885.00,2065.50,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISS ALLOGRAFT UMB 3X5CM,10361889,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5885.00,1765.50,2283.38,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2283.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5002.25,,,percent of total billed charges,,,2648.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISS ALLOGRAFT UMB 3X5CM,10361889,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5885.00,1765.50,2471.70,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2968.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5002.25,,,percent of total billed charges,,,2707.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISS AMNIOCORD STR 2X3CM,10361890,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISS AMNIOCORD STR 2X3CM,10361890,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISS AMNIOCORD STR 2X3CM,10361890,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,3716.00,1114.80,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 20.5,10361891,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 20.5,10361891,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TENDON 4.5 X 150-250MM,10361892,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4230.00,1269.00,1641.24,3595.5,,,,,,,,,,,,,,,,,,,,1641.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2115.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3595.5,,,percent of total billed charges,,,1903.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TENDON 4.5 X 150-250MM,10361892,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4230.00,1269.00,1797.75,3595.5,,,,,,,,,,,,,service not payable,,,,,,,2133.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1797.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2115.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3172.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3595.5,,,percent of total billed charges,,,1945.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TRANSEND EX .014 PLT,10361893,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,1350.95,,,percent of total billed charges,,,,,,,,service not payable,1066.77,,,percent of total billed charges,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,1420.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1420.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM GLOBAL UNITE 12.5MM,10361895,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM GLOBAL UNITE 12.5MM,10361895,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 605CC,10361897,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 605CC,10361897,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS PENILE 700MS 12X12,10362290,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,30850.00,9255.00,11969.80,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11969.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26222.5,,,percent of total billed charges,,,13882.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS PENILE 700MS 12X12,10362290,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,30850.00,9255.00,12957.0,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15560.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26222.5,,,percent of total billed charges,,,14191.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS PENILE 700MS 21CM,10362291,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,30850.00,9255.00,11969.80,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11969.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26222.5,,,percent of total billed charges,,,13882.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS PENILE 700MS 21CM,10362291,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,30850.00,9255.00,12957.0,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15560.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26222.5,,,percent of total billed charges,,,14191.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC  43X37MM,10362292,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,43699.00,13109.70,16955.21,37144.15,,21412.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18353.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16955.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18572.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32774.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21849.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37144.15,,,percent of total billed charges,,,19664.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC  43X37MM,10362292,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,43699.00,13109.70,18353.58,37144.15,,21412.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18353.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,22041.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18572.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32774.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21849.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32774.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,37144.15,,,percent of total billed charges,,,20101.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC  43 218MM,10362293,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,46977.00,14093.10,18227.08,39930.45,,23018.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19730.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,18227.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19965.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,35232.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23488.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39930.45,,,percent of total billed charges,,,21139.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC  43 218MM,10362293,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,46977.00,14093.10,19730.34,39930.45,,23018.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19730.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,23695.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,19965.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,35232.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,23488.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,35232.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,39930.45,,,percent of total billed charges,,,21609.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 95MM,10362294,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,40421.00,12126.30,15683.35,34357.85,,19806.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16976.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15683.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17178.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,30315.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20210.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34357.85,,,percent of total billed charges,,,18189.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 95MM,10362294,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,40421.00,12126.30,16976.82,34357.85,,19806.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16976.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,20388.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17178.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,30315.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20210.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,30315.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34357.85,,,percent of total billed charges,,,18593.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 2 LVL 42MM,10362295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 2 LVL 42MM,10362295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 12X14MMX8MM,10362296,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 12X14MMX8MM,10362296,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT X3 TRIATHLON PS 2 14MM,10362297,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT X3 TRIATHLON PS 2 14MM,10362297,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX HEADED 33MM,10362298,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,525.00,157.50,203.70,446.25,,,,,,,,,,,,,,,,,,,,203.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX HEADED 33MM,10362298,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.12,446.25,,,,,,,,,,,,,service not payable,,,,,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEX HEADED 48MM,10362299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,525.00,157.50,203.70,446.25,,,,,,,,,,,,,,,,,,,,203.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEX HEADED 48MM,10362299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.12,446.25,,,,,,,,,,,,,service not payable,,,,,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PF J CMNT SZ3 LT,10362300,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13703.00,4110.90,5316.76,11647.55,,6714.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5755.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5316.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5823.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10277.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11647.55,,,percent of total billed charges,,,6166.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PF J CMNT SZ3 LT,10362300,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13703.00,4110.90,5755.26,11647.55,,6714.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5755.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6911.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5823.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10277.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10277.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11647.55,,,percent of total billed charges,,,6303.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ALL-POLY PATELLA 32MM 8.5,10362301,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ALL-POLY PATELLA 32MM 8.5,10362301,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PENILE PRECONNECT 24CM,10362302,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,30850.00,9255.00,11969.80,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11969.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26222.5,,,percent of total billed charges,,,13882.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PENILE PRECONNECT 24CM,10362302,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,30850.00,9255.00,12957.0,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15560.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26222.5,,,percent of total billed charges,,,14191.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PENILE PRECONNECT 12CM,10362303,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,31813.00,9543.90,12343.44,27041.05,,15588.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13361.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12343.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13520.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15906.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27041.05,,,percent of total billed charges,,,14315.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PENILE PRECONNECT 12CM,10362303,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,31813.00,9543.90,13361.46,27041.05,,15588.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13361.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16046.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13520.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23859.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15906.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23859.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27041.05,,,percent of total billed charges,,,14633.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PENILE PRECONNECT 14CM,10362304,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,31813.00,9543.90,12343.44,27041.05,,15588.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13361.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12343.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13520.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15906.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27041.05,,,percent of total billed charges,,,14315.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PENILE PRECONNECT 14CM,10362304,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,31813.00,9543.90,13361.46,27041.05,,15588.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13361.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16046.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13520.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23859.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15906.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23859.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27041.05,,,percent of total billed charges,,,14633.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PENILE PRECONNECT 16CM,10362305,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,31813.00,9543.90,12343.44,27041.05,,15588.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13361.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12343.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13520.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15906.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27041.05,,,percent of total billed charges,,,14315.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PENILE PRECONNECT 16CM,10362305,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,31813.00,9543.90,13361.46,27041.05,,15588.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13361.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16046.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13520.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23859.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15906.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23859.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27041.05,,,percent of total billed charges,,,14633.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROXIMAL 20F 2X28X124MM,10362307,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24762.00,7428.60,9607.66,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9607.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21047.70,,,percent of total billed charges,,,11142.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROXIMAL 20F 2X28X124MM,10362307,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24762.00,7428.60,10400.04,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12489.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21047.70,,,percent of total billed charges,,,11390.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTICULAR CD 3-4 12MM,10362308,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTICULAR CD 3-4 12MM,10362308,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LCKG 3.5X10MM,10362309,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LCKG 3.5X10MM,10362309,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LCKG 3.5X12MM,10362310,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LCKG 3.5X12MM,10362310,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LCKG 3.5X14MM,10362311,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LCKG 3.5X14MM,10362311,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LCKG 3.5X18MM,10362312,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LCKG 3.5X18MM,10362312,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LCKG 3.5X20MM,10362313,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LCKG 3.5X20MM,10362313,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB RT 3H LCKG,10362314,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4164.00,1249.20,1615.63,3539.40,,,,,,,,,,,,,,,,,,,,1615.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2082.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3539.40,,,percent of total billed charges,,,1873.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB RT 3H LCKG,10362314,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4164.00,1249.20,1769.7,3539.40,,,,,,,,,,,,,service not payable,,,,,,,2100.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1769.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2082.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3539.40,,,percent of total billed charges,,,1915.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER MICRO PHENOM 17 150CM X_G11150-0615-2S X_,10362315,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.78,3623.55,,2634.53,,,percent of total billed charges,,,,,,,,service not payable,2080.34,,,percent of total billed charges,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.78,,,percent of total billed charges,,,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,2770.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2770.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON PTA 75X18X6 X_AT75186 X_BARD,10362316,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SZ CD 3-4 12MM,10362317,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SZ CD 3-4 12MM,10362317,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ9 5MM X_1516-20-905 X_DEPUY,10362499,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ9 5MM X_1516-20-905 X_DEPUY,10362499,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEAD SPHERE 6.5X50MM X_71332550 X_SMITH NEPH,10362504,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,268.00,80.40,103.98,227.80,,,,,,,,,,,,,,,,,,,,103.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,201.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,,120.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEAD SPHERE 6.5X50MM X_71332550 X_SMITH NEPH,10362504,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,268.00,80.40,113.90,227.80,,,,,,,,,,,,,service not payable,,,,,,,135.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,113.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,201.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,134.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,201.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM ATTUNE PS CEM SZ6 LT,10362505,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM ATTUNE PS CEM SZ6 LT,10362505,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR RP SZ6 10MM,10362506,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR RP SZ6 10MM,10362506,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE POS FEM AUG SZ 6 4MM,10362507,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE POS FEM AUG SZ 6 4MM,10362507,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB CANN 10X360MM,10362508,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6851.00,2055.30,2658.19,5823.35,,3356.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2877.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2658.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2911.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5138.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3425.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5823.35,,,percent of total billed charges,,,3082.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB CANN 10X360MM,10362508,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6851.00,2055.30,2877.42,5823.35,,3356.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2877.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3455.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2911.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5138.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3425.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5138.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5823.35,,,percent of total billed charges,,,3151.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BIOSURE PK KNEE 7X30MM,10362509,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1536.00,460.80,595.97,1305.60,,,,,,,,,,,,,,,,,,,,595.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1152.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,768.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.60,,,percent of total billed charges,,,691.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIOSURE PK KNEE 7X30MM,10362509,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1536.00,460.80,652.80,1305.60,,,,,,,,,,,,,service not payable,,,,,,,774.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,652.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1152.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,768.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1152.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1305.60,,,percent of total billed charges,,,706.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE TROCAR TIP DISP 0.045IN,10362510,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,143.00,42.90,60.77,121.55,,88.37,,,percent of total billed charges,,,,,,,,service not payable,69.78,,,percent of total billed charges,,,72.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.77,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,,,service not payable,107.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,92.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE COMPRESSION 4X20MM,10362511,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE COMPRESSION 4X20MM,10362511,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUT RELOAD CARTRIDGE 2.0,10362514,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2470.00,741.00,958.36,2099.5,,,,,,,,,,,,,,,,,,,,958.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.5,,,percent of total billed charges,,,1111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUT RELOAD CARTRIDGE 2.0,10362514,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2470.00,741.00,1049.75,2099.5,,,,,,,,,,,,,service not payable,,,,,,,1245.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1852.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1235.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1852.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2099.5,,,percent of total billed charges,,,1136.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE DXTEND STD 382MM,10362517,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE DXTEND STD 382MM,10362517,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP CLAV 3.5X120MM 8H,10362518,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7095.00,2128.50,2752.86,6030.75,,3476.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2979.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2752.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3015.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5321.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6030.75,,,percent of total billed charges,,,3192.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP CLAV 3.5X120MM 8H,10362518,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7095.00,2128.50,2979.90,6030.75,,3476.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2979.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3578.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3015.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5321.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3547.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5321.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6030.75,,,percent of total billed charges,,,3263.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SHOULDER 42MM PERFORM P,10362519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,672.00,201.60,260.74,571.20,,,,,,,,,,,,,,,,,,,,260.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.20,,,percent of total billed charges,,,302.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SHOULDER 42MM PERFORM P,10362519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,672.00,201.60,285.60,571.20,,,,,,,,,,,,,service not payable,,,,,,,338.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,571.20,,,percent of total billed charges,,,309.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 770CC,10362520,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 770CC,10362520,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 295CC,10363135,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 295CC,10363135,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 310CC,10363136,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 310CC,10363136,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 330CC,10363137,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 330CC,10363137,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 345CC,10363138,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 345CC,10363138,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 360CC,10363139,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 360CC,10363139,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 375CC,10363140,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 375CC,10363140,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 495CC,10363141,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 495CC,10363141,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 200CC,10363143,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 200CC,10363143,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 230CC,10363144,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 230CC,10363144,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 260CC,10363145,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 260CC,10363145,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 190CC,10363146,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 190CC,10363146,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 205CC,10363147,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 205CC,10363147,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 220CC,10363148,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 220CC,10363148,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 235CC,10363149,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 235CC,10363149,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 250CC,10363150,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 250CC,10363150,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 210CC,10363151,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 210CC,10363151,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 240CC,10363152,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 240CC,10363152,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 255CC,10363153,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 255CC,10363153,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 275CC,10363154,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 275CC,10363154,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATH AORTIC 23MM,10363155,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATH AORTIC 23MM,10363155,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATH AORTIC 26MM,10363156,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATH AORTIC 26MM,10363156,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATH AORTIC 29MM,10363157,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATH AORTIC 29MM,10363157,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE TRANSCATH AORTIC 34MM,10363158,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE TRANSCATH AORTIC 34MM,10363158,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DILATION 6F 8MMX2CM 135CM,10363163,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,858.00,257.40,364.65,729.30,,530.24,,,percent of total billed charges,,,,,,,,service not payable,418.70,,,percent of total billed charges,,,432.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,364.65,,,percent of total billed charges,,,,,,,,,643.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,429.0,,,percent of total billed charges,,,,,,,,service not payable,643.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,729.30,,,percent of total billed charges,,,394.68,,,percent of total billed charges,,,,,,,,,557.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,557.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TENDON SCL FROZEN X_FGLTS X_LIFENET,10363165,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TENDON SCL FROZEN X_FGLTS X_LIFENET,10363165,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Replace/Remove Cardio- Defib Generator dual lead,10363347,CDM,0481,RC,33263,CPT,,,,,,outpatient,facility,,,52178.00,15653.40,4917.20,50947.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,26318.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,39133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50947.0,,,case rate,,,,,,,,,39133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44351.30,,,percent of total billed charges,,,24001.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Replace/Remove Cardio- Defib Generator dual lead,10363347,CDM,0481,RC,33263,CPT,05231,APC,,,,outpatient,facility,,,52178.00,15653.40,20646.60,49437.86,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,45281.58,,,fee schedule,,,20646.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21900.60,,,fee schedule,,,49437.86,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,44625.33,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,20646.60,,,fee schedule,,,21900.60,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,20646.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",21900.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,21685.55,,,fee schedule,,,,,,,,
Replace/Remove Cardio- Defib Generator dual lead,10363347,CDM,0481,RC,33263,CPT,97,EAPG,,,,outpatient,facility,,,52178.00,15653.40,32245.61,50588.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50588.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,42999.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42921.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,47214.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG Coma or Sleep Only,10363357,CDM,0740,RC,95822,CPT,,,,,,outpatient,facility,,,792.00,237.60,336.60,726.0,,489.46,,,percent of total billed charges,,,,,,,,,386.5,,,percent of total billed charges,,,399.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.60,,,percent of total billed charges,,,,,,,,,594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.0,,,percent of total billed charges,,,,,,,,,594.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,673.20,,,percent of total billed charges,,,364.32,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG Coma or Sleep Only,10363357,CDM,0740,RC,95822,CPT,05722,APC,,,,outpatient,facility,,,792.00,237.60,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-EEG Coma or Sleep Only,10363357,CDM,0740,RC,95822,CPT,211,EAPG,,,,outpatient,facility,,,792.00,237.60,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COIL EMBOL RUBY POD 10MMX60CM,10363736,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5868.00,1760.40,2276.78,4987.80,,2875.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2464.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2276.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2493.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4401.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4987.80,,,percent of total billed charges,,,2640.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL EMBOL RUBY POD 10MMX60CM,10363736,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5868.00,1760.40,2464.56,4987.80,,2875.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2464.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2959.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2493.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4401.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4401.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4987.80,,,percent of total billed charges,,,2699.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 2.5X26MM,10365148,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2708.00,812.40,1050.70,2301.80,,,,,,,,,,,,,,,,,,,,1050.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,,1218.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X26MM,10365148,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2708.00,812.40,1150.90,2301.80,,,,,,,,,,,,,service not payable,,,,,,,1365.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,,1245.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 3.5X16MM,10365149,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 3.5X16MM,10365149,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 48X18MM,10365150,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11779.00,3533.70,4570.25,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4570.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10012.15,,,percent of total billed charges,,,5300.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 48X18MM,10365150,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11779.00,3533.70,4947.18,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5941.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10012.15,,,percent of total billed charges,,,5418.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE PEEK 11X24 4 DEGREE,10365151,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PEEK 11X24 4 DEGREE,10365151,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
POST SHOULDER GLENOID 6.5X35MM,10365152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POST SHOULDER GLENOID 6.5X35MM,10365152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER ELITE 10MMX10-14MM 12 D,10365153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER ELITE 10MMX10-14MM 12 D,10365153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL CUP FEM ACETABULAR 50MM,10365154,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL CUP FEM ACETABULAR 50MM,10365154,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP ST HDLS 4X28MM,10365155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP ST HDLS 4X28MM,10365155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VARIAX COMPR BROAD 4H,10365156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1881.00,564.30,729.83,1598.85,,,,,,,,,,,,,,,,,,,,729.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1410.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,940.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1598.85,,,percent of total billed charges,,,846.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VARIAX COMPR BROAD 4H,10365156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1881.00,564.30,799.42,1598.85,,,,,,,,,,,,,service not payable,,,,,,,948.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,799.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1410.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,940.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1410.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1598.85,,,percent of total billed charges,,,865.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE T STND 2.3MM 7H X_57-10160 X_STRYKER ORTHOPA,10365157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1131.00,339.30,438.83,961.35,,,,,,,,,,,,,,,,,,,,438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.35,,,percent of total billed charges,,,508.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE T STND 2.3MM 7H X_57-10160 X_STRYKER ORTHOPA,10365157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1131.00,339.30,480.68,961.35,,,,,,,,,,,,,service not payable,,,,,,,570.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,848.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,961.35,,,percent of total billed charges,,,520.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 325CC,10365158,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 325CC,10365158,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 345CC,10365159,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 345CC,10365159,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 365CC,10365160,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 365CC,10365160,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COVER CIRCAID LWR LEG BLK L,10365161,CDM,0272,RC,A6545,HCPCS,,,,,,outpatient,facility,,,62.00,18.60,26.35,140.12,,38.32,,,percent of total billed charges,,,61.01,,,fee schedule,,,30.26,,,percent of total billed charges,,,31.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,128.34,,,fee schedule,,,,,,,,service not payable,62.23,,,fee schedule,,,140.12,,,fee schedule,,,,,,,,,61.01,,,fee schedule,,,,,,,,,26.35,,,percent of total billed charges,,,126.48,,,fee schedule,,,46.5,,,percent of total billed charges,,,61.01,,,fee schedule,,,,,,,,service not payable,62.23,,,fee schedule,,,31.0,,,percent of total billed charges,,,61.01,,,fee schedule,,,46.5,,,percent of total billed charges,,,,,,,,service not payable,62.23,,,fee schedule,,,,,,,,,52.70,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,,,,,,,40.30,,,percent of total billed charges,,,61.01,,,fee schedule,,,,,,,,,40.30,,,percent of total billed charges,,,61.01,,,fee schedule,,,,,,,,,61.01,,,fee schedule,,,,,,,,
COVER CIRCAID LWR LEG BLK S,10365162,CDM,0272,RC,A6545,HCPCS,,,,,,outpatient,facility,,,62.00,18.60,26.35,140.12,,38.32,,,percent of total billed charges,,,61.01,,,fee schedule,,,30.26,,,percent of total billed charges,,,31.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,128.34,,,fee schedule,,,,,,,,service not payable,62.23,,,fee schedule,,,140.12,,,fee schedule,,,,,,,,,61.01,,,fee schedule,,,,,,,,,26.35,,,percent of total billed charges,,,126.48,,,fee schedule,,,46.5,,,percent of total billed charges,,,61.01,,,fee schedule,,,,,,,,service not payable,62.23,,,fee schedule,,,31.0,,,percent of total billed charges,,,61.01,,,fee schedule,,,46.5,,,percent of total billed charges,,,,,,,,service not payable,62.23,,,fee schedule,,,,,,,,,52.70,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,,,,,,,40.30,,,percent of total billed charges,,,61.01,,,fee schedule,,,,,,,,,40.30,,,percent of total billed charges,,,61.01,,,fee schedule,,,,,,,,,61.01,,,fee schedule,,,,,,,,
LEAD PACING TEMPO TEMPORARY 6F,10365166,CDM,0278,RC,C1883,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACING TEMPO TEMPORARY 6F,10365166,CDM,0278,RC,C1883,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE COMPONENT TIB MD,10365168,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1968.00,590.40,763.58,1672.8,,,,,,,,,,,,,,,,,,,,763.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1672.8,,,percent of total billed charges,,,885.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE COMPONENT TIB MD,10365168,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1968.00,590.40,836.40,1672.8,,,,,,,,,,,,,service not payable,,,,,,,992.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1672.8,,,percent of total billed charges,,,905.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE COMPONENT TIB LG,10365169,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE COMPONENT TIB LG,10365169,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Coronary Sinus Mapping,10365434,CDM,0481,RC,93621,CPT,,,,,,outpatient,facility,,,12021.00,3606.30,1106.0,11611.47,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,8909.33,,,case rate,,,6063.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,9015.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,9015.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10217.85,,,percent of total billed charges,,,5529.66,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Coronary Sinus Mapping,10365434,CDM,0481,RC,93621,CPT,96,EAPG,,,,outpatient,facility,,,12021.00,3606.30,9268.92,18075.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18075.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,15364.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9268.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,9268.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,9268.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14048.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,15453.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Anes Moderate sedation other phys any age ea ad,10365590,CDM,0379,RC,99157,CPT,,,,,,outpatient,facility,,,253.00,75.90,107.53,215.05,,156.35,,,percent of total billed charges,,,,,,,,service not payable,123.46,,,percent of total billed charges,,,127.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,107.53,,,percent of total billed charges,,,,,,,,,189.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,126.5,,,percent of total billed charges,,,,,,,,service not payable,189.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,215.05,,,percent of total billed charges,,,116.38,,,percent of total billed charges,,,,,,,,,164.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,164.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Anes Moderate sedation other phys any age ea ad,10365590,CDM,0379,RC,99157,CPT,380,EAPG,,,,outpatient,facility,,,253.00,75.90,33.12,65.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,48.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Percutaneous Transluminal Coronary Thrombectomy Me,10365597,CDM,0481,RC,92973,CPT,,,,,,outpatient,facility,,,5821.00,1746.30,1106.0,4947.85,,3597.38,,,percent of total billed charges,,,,,,,,service not payable,2840.65,,,percent of total billed charges,,,2936.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,4365.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,4365.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4947.85,,,percent of total billed charges,,,2677.66,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Percutaneous Transluminal Coronary Thrombectomy Me,10365597,CDM,0481,RC,92973,CPT,99,EAPG,,,,outpatient,facility,,,5821.00,1746.30,5821.0,22868.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22868.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,19438.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5821.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5821.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5821.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13448.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,14793.26,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INF OP VISIT ESTAB PATIENT STRAIGHTFORWARD 10-19,10365633,CDM,0942,RC,G0463,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,312.0,,101.97,,,percent of total billed charges,,,,,,,,,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,312.0,,,per diem,,,,,,,,,,,,,,,275.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
INF OP VISIT ESTAB PATIENT STRAIGHTFORWARD 10-19,10365633,CDM,0942,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,165.00,49.50,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
INF OP VISIT ESTAB PATIENT STRAIGHTFORWARD 10-19,10365633,CDM,0942,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,165.00,49.50,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INF OP VISIT ESTAB PATIENT STRAIGHTFORWARD 10-19,10365633,CDM,0510,RC,99212,CPT,,,,,,outpatient,facility,,,318.00,95.40,146.28,270.30,,196.52,,,percent of total billed charges,,,,,,,,service not payable,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,238.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,206.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,206.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INF OP VISIT ESTAB PATIENT STRAIGHTFORWARD 10-19,10365633,CDM,0510,RC,99212,CPT,852,EAPG,,,,outpatient,facility,,,318.00,95.40,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Remove Transvenous Pacemaker Electrode Dual Lead,10365779,CDM,0481,RC,33235,CPT,,,,,,outpatient,facility,,,9781.00,2934.30,4499.26,8313.85,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,4933.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,7335.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,7335.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8313.85,,,percent of total billed charges,,,4499.26,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Remove Transvenous Pacemaker Electrode Dual Lead,10365779,CDM,0481,RC,33235,CPT,05221,APC,,,,outpatient,facility,,,9781.00,2934.30,3347.52,8015.59,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7341.71,,,fee schedule,,,3347.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3559.77,,,fee schedule,,,8015.59,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7235.31,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,3347.52,,,fee schedule,,,3559.77,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3347.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3559.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3524.73,,,fee schedule,,,,,,,,
Remove Transvenous Pacemaker Electrode Dual Lead,10365779,CDM,0481,RC,33235,CPT,74,EAPG,,,,outpatient,facility,,,9781.00,2934.30,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert/Replace Permanent Pacemaker,10366274,CDM,0481,RC,33208,CPT,,,,,,outpatient,facility,,,20789.00,6236.70,8909.33,28801.0,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,10485.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,15591.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,15591.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17670.65,,,percent of total billed charges,,,9562.94,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert/Replace Permanent Pacemaker,10366274,CDM,0481,RC,33208,CPT,05223,APC,,,,outpatient,facility,,,20789.00,6236.70,9626.29,23049.94,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,21112.12,,,fee schedule,,,9626.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10229.20,,,fee schedule,,,23049.94,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,20806.14,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,9626.29,,,fee schedule,,,10229.20,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,9626.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",10229.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,10128.58,,,fee schedule,,,,,,,,
Insert/Replace Permanent Pacemaker,10366274,CDM,0481,RC,33208,CPT,86,EAPG,,,,outpatient,facility,,,20789.00,6236.70,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL ACETABULAR 56MM F,10366385,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR 56MM F,10366385,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FRACTURE LOCK 2.7X30MM,10366387,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FRACTURE LOCK 2.7X30MM,10366387,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LO-PRO LOCK 2.7X38MM,10366388,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LO-PRO LOCK 2.7X38MM,10366388,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LO-PRO LOCK 2.7X40MM,10366389,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,629.00,188.70,244.05,534.65,,,,,,,,,,,,,,,,,,,,244.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.65,,,percent of total billed charges,,,283.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LO-PRO LOCK 2.7X40MM,10366389,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,,,,,,,,,,,,service not payable,,,,,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LP SHORT 30X4.0MM,10366390,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LP SHORT 30X4.0MM,10366390,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB DISTAL MEDIA 4H LT,10366391,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5639.00,1691.70,2187.93,4793.15,,2763.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2368.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2187.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2396.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4793.15,,,percent of total billed charges,,,2537.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB DISTAL MEDIA 4H LT,10366391,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5639.00,1691.70,2368.38,4793.15,,2763.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2368.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2844.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2396.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4793.15,,,percent of total billed charges,,,2593.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM DISTAL TIBIA,10366392,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,25522.00,7656.60,9902.54,21693.70,,12505.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10719.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9902.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10846.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12761.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21693.70,,,percent of total billed charges,,,11484.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM DISTAL TIBIA,10366392,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,25522.00,7656.60,10719.24,21693.70,,12505.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10719.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12873.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10846.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19141.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12761.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19141.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21693.70,,,percent of total billed charges,,,11740.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MAGNET IMPLANT BAHA 4 4MM,10366394,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,6711.00,2013.30,2603.87,5704.35,,3288.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2818.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2603.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2852.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5033.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5704.35,,,percent of total billed charges,,,3019.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNET IMPLANT BAHA 4 4MM,10366394,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,6711.00,2013.30,2818.62,5704.35,,3288.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2818.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3385.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2852.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5033.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5033.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5704.35,,,percent of total billed charges,,,3087.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT POWER BAHA 5 BROWN,10366395,CDM,0278,RC,L8690,HCPCS,,,,,,inpatient,facility,,,11525.00,3457.50,4471.70,9796.25,,5647.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4840.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4471.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4898.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9796.25,,,percent of total billed charges,,,5186.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT POWER BAHA 5 BROWN,10366395,CDM,0278,RC,L8690,HCPCS,,,,,,outpatient,facility,,,11525.00,3457.50,4840.5,9796.25,,5647.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4840.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5813.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4898.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9796.25,,,percent of total billed charges,,,5301.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL LT SZ 5-6 9MM,10366400,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1768.00,530.40,685.98,1502.8,,,,,,,,,,,,,,,,,,,,685.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,751.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1326.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,884.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1502.8,,,percent of total billed charges,,,795.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL LT SZ 5-6 9MM,10366400,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1768.00,530.40,751.40,1502.8,,,,,,,,,,,,,service not payable,,,,,,,891.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,751.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1326.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,884.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1326.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1502.8,,,percent of total billed charges,,,813.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CONDYLE LT SZ 6,10366401,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CONDYLE LT SZ 6,10366401,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL HEX 14X2.7MM,10366402,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,454.00,136.20,176.15,385.90,,,,,,,,,,,,,,,,,,,,176.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,,204.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL HEX 14X2.7MM,10366402,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,454.00,136.20,192.95,385.90,,,,,,,,,,,,,service not payable,,,,,,,229.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,340.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,,208.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL HEX 16X2.7MM,10366403,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,454.00,136.20,176.15,385.90,,,,,,,,,,,,,,,,,,,,176.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.90,,,percent of total billed charges,,,204.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL HEX 16X2.7MM,10366403,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,454.00,136.20,192.95,385.90,,,,,,,,,,,,,service not payable,,,,,,,229.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,340.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,227.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,340.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,385.90,,,percent of total billed charges,,,208.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX38CM 130DEG 1.5 RT,10366404,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5002.00,1500.60,1940.78,4251.70,,2450.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2100.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1940.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2125.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3751.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4251.70,,,percent of total billed charges,,,2250.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX38CM 130DEG 1.5 RT,10366404,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5002.00,1500.60,2100.84,4251.70,,2450.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2100.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2125.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3751.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3751.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4251.70,,,percent of total billed charges,,,2300.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM VERSA OFF 42X18X46MM,10366405,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM VERSA OFF 42X18X46MM,10366405,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT AMNIOFILL 2000,10366406,CDM,0278,RC,V2790,HCPCS,,,,,,inpatient,facility,,,13441.00,4032.30,5215.11,11424.85,,6586.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5645.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5215.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5712.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10080.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6720.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11424.85,,,percent of total billed charges,,,6048.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT AMNIOFILL 2000,10366406,CDM,0278,RC,V2790,HCPCS,,,,,,outpatient,facility,,,13441.00,4032.30,5645.22,11424.85,,6586.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5645.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6779.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5712.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10080.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6720.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10080.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11424.85,,,percent of total billed charges,,,6182.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT AMNIOFILL 2000,10366406,CDM,0278,RC,V2790,HCPCS,455,EAPG,,,,outpatient,facility,,,13441.00,4032.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VEGA PS GLIDE SURF T1/T1 14MM,10366407,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VEGA PS GLIDE SURF T1/T1 14MM,10366407,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR ICONIX 2.3MM,10366409,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2546.00,763.80,987.85,2164.10,,,,,,,,,,,,,,,,,,,,987.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1082.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1909.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2164.10,,,percent of total billed charges,,,1145.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR ICONIX 2.3MM,10366409,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2546.00,763.80,1082.05,2164.10,,,,,,,,,,,,,service not payable,,,,,,,1284.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1082.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1909.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1909.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2164.10,,,percent of total billed charges,,,1171.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Repair Simple Wound 2.5cm or < Scalp Neck Tru,10366668,CDM,0761,RC,12001,CPT,,,,,,outpatient,facility,,,580.00,174.00,118.0,493.0,,358.44,,,percent of total billed charges,,,,,,,,,283.04,,,percent of total billed charges,,,292.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,,,,,,,,435.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,290.0,,,percent of total billed charges,,,,,,,,,435.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,493.0,,,percent of total billed charges,,,266.80,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Repair Simple Wound 2.5cm or < Scalp Neck Tru,10366668,CDM,0761,RC,12001,CPT,05051,APC,,,,outpatient,facility,,,580.00,174.00,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Repair Simple Wound 2.5cm or < Scalp Neck Tru,10366668,CDM,0761,RC,12001,CPT,16,EAPG,,,,outpatient,facility,,,580.00,174.00,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Repair Simple Wound 2.6-7.5 cm Scalp Neck Tr,10366669,CDM,0761,RC,12002,CPT,,,,,,outpatient,facility,,,437.00,131.10,118.0,371.45,,270.07,,,percent of total billed charges,,,,,,,,,213.26,,,percent of total billed charges,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Repair Simple Wound 2.6-7.5 cm Scalp Neck Tr,10366669,CDM,0761,RC,12002,CPT,05051,APC,,,,outpatient,facility,,,437.00,131.10,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Repair Simple Wound 2.6-7.5 cm Scalp Neck Tr,10366669,CDM,0761,RC,12002,CPT,16,EAPG,,,,outpatient,facility,,,437.00,131.10,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Remove/Replace Pulse Generator Single Lead,10366690,CDM,0481,RC,33227,CPT,,,,,,outpatient,facility,,,16829.00,5048.70,4917.20,18583.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,8488.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,12621.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,12621.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14304.65,,,percent of total billed charges,,,7741.34,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Remove/Replace Pulse Generator Single Lead,10366690,CDM,0481,RC,33227,CPT,05222,APC,,,,outpatient,facility,,,16829.00,5048.70,7612.46,18227.89,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16695.46,,,fee schedule,,,7612.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8095.12,,,fee schedule,,,18227.89,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16453.5,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,7612.46,,,fee schedule,,,8095.12,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,7612.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",8095.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,8015.43,,,fee schedule,,,,,,,,
Remove/Replace Pulse Generator Single Lead,10366690,CDM,0481,RC,33227,CPT,86,EAPG,,,,outpatient,facility,,,16829.00,5048.70,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Remove AICD Electrod,10366704,CDM,0481,RC,33244,CPT,,,,,,outpatient,facility,,,5128.00,1538.40,2358.88,6509.0,,5128.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,2586.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,3846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,3846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4358.80,,,percent of total billed charges,,,2358.88,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Remove AICD Electrod,10366704,CDM,0481,RC,33244,CPT,05221,APC,,,,outpatient,facility,,,5128.00,1538.40,3347.52,8015.59,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7341.71,,,fee schedule,,,3347.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3559.77,,,fee schedule,,,8015.59,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7235.31,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,3347.52,,,fee schedule,,,3559.77,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3347.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3559.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3524.73,,,fee schedule,,,,,,,,
Remove AICD Electrod,10366704,CDM,0481,RC,33244,CPT,74,EAPG,,,,outpatient,facility,,,5128.00,1538.40,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert Lead Single Chamber ICD,10366705,CDM,0481,RC,33216,CPT,,,,,,outpatient,facility,,,9835.00,2950.50,4524.10,12795.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert Lead Single Chamber ICD,10366705,CDM,0481,RC,33216,CPT,05222,APC,,,,outpatient,facility,,,9835.00,2950.50,7612.46,18227.89,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16695.46,,,fee schedule,,,7612.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8095.12,,,fee schedule,,,18227.89,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16453.50,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,7612.46,,,fee schedule,,,8095.12,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,7612.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",8095.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,8015.43,,,fee schedule,,,,,,,,
Insert Lead Single Chamber ICD,10366705,CDM,0481,RC,33216,CPT,74,EAPG,,,,outpatient,facility,,,9835.00,2950.50,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Testosterone Adult Male Panel Free,10366852,CDM,0300,RC,84402,CPT,,,,,,outpatient,facility,,,66.00,19.80,24.20,66.0,,66.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,24.96,,,fee schedule,,,66.0,,,fee schedule,,,53.12,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,52.72,,,fee schedule,,,24.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",25.46,,,fee schedule,,,57.56,,,fee schedule,,,,,,,,,24.96,,,fee schedule,,,,,,,,,32.86,,,fee schedule,,,51.96,,,fee schedule,,,49.5,,,percent of total billed charges,,,24.96,,,fee schedule,,,24.20,,,fee schedule,,,25.46,,,fee schedule,,,38.64,,,fee schedule,,,24.96,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,25.46,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,28.02,,,fee schedule,,,24.96,,,fee schedule,,,,,,,,,24.71,,,fee schedule,,,24.96,,,fee schedule,,,,,,,,,25.21,,,fee schedule,,,,,,,,
Testosterone Adult Male Panel Free,10366852,CDM,0300,RC,84402,CPT,398,EAPG,,,,outpatient,facility,,,66.00,19.80,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
RT- Bronchoscopy rigid or flexible fluoro guidan,10367112,CDM,0490,RC,31626,CPT,,,,,,outpatient,facility,,,13455.00,4036.50,4700.0,11436.75,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,6786.70,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,10091.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,10091.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11436.75,,,percent of total billed charges,,,6189.30,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
RT- Bronchoscopy rigid or flexible fluoro guidan,10367112,CDM,0490,RC,31626,CPT,05155,APC,,,,outpatient,facility,,,13455.00,4036.50,6367.47,15246.77,,,,,,,,6638.42,,,fee schedule,,,,,,,,,,,,,,,13964.97,,,fee schedule,,,6367.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6771.19,,,fee schedule,,,15246.77,,,fee schedule,,,,,,,,,6638.42,,,fee schedule,,,,,,,,,,,,,,,13762.57,,,fee schedule,,,,,,,,,6638.42,,,fee schedule,,,6367.47,,,fee schedule,,,6771.19,,,fee schedule,,,,,,,,,6638.42,,,fee schedule,,,,,,,,,6367.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",6771.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6638.42,,,fee schedule,,,,,,,,,,,,,,,6638.42,,,fee schedule,,,,,,,,,6704.53,,,fee schedule,,,,,,,,
RT- Bronchoscopy rigid or flexible fluoro guidan,10367112,CDM,0490,RC,31626,CPT,64,EAPG,,,,outpatient,facility,,,13455.00,4036.50,1824.04,6789.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6789.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5771.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2607.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2607.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2607.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1824.04,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2006.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Removal IA Balloon Assist Device,10367266,CDM,0481,RC,33968,CPT,,,,,,outpatient,facility,,,1836.00,550.80,36.82,40166.0,,1836.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,926.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,32559.0,,,case rate,,,,,,,,,1377.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,38305.0,,,case rate,,,,,,,,service not payable,1377.0,,,percent of total billed charges,,,36.82,,,fee schedule,,,,,,,,service not payable,,,,,,,1560.60,,,percent of total billed charges,,,844.56,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,service not payable,,,,,,,35346.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Removal IA Balloon Assist Device,10367266,CDM,0481,RC,33968,CPT,87,EAPG,,,,outpatient,facility,,,1836.00,550.80,1836.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1836.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1836.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1836.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert Temp Ventricular Assist Device,10367267,CDM,0481,RC,33990,CPT,,,,,,outpatient,facility,,,7103.00,2130.90,315.44,7856.0,,7103.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,3582.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,315.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,5327.25,,,percent of total billed charges,,,,,,,,service not payable,315.44,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,5327.25,,,percent of total billed charges,,,315.44,,,fee schedule,,,,,,,,service not payable,,,,,,,6037.55,,,percent of total billed charges,,,3267.38,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert Temp Ventricular Assist Device,10367267,CDM,0481,RC,33990,CPT,3060,EAPG,,,,outpatient,facility,,,7103.00,2130.90,7103.0,83927.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83927.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,71338.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,7103.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,57974.96,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,63772.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
IMPLANT BRST INSPIRA SSM 405CC,10367272,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 405CC,10367272,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 445CC,10367273,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 445CC,10367273,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 485CC,10367274,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 485CC,10367274,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 385CC,10367275,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 385CC,10367275,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 415CC,10367276,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 415CC,10367276,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 450CC,10367277,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 450CC,10367277,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 485CC,10367278,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 485CC,10367278,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 5 10MM,10367279,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 5 10MM,10367279,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT SAC IFUSE 7.0X45MM,10367280,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT SAC IFUSE 7.0X45MM,10367280,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT SAC IFUSE 7.0X55MM,10367281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT SAC IFUSE 7.0X55MM,10367281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB ROTATING CEM SZ6,10367282,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17663.00,5298.90,6853.24,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6853.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15013.55,,,percent of total billed charges,,,7948.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB ROTATING CEM SZ6,10367282,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17663.00,5298.90,7418.46,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8909.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15013.55,,,percent of total billed charges,,,8124.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE WHISPER MS 3X300CM,10367285,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 3.5X32MM,10367286,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7049.00,2114.70,2735.01,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2735.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5991.65,,,percent of total billed charges,,,3172.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 3.5X32MM,10367286,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7049.00,2114.70,2960.58,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3555.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5991.65,,,percent of total billed charges,,,3242.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 3.5X36MM,10367287,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 3.5X36MM,10367287,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 3.5X26MM,10367288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 3.5X26MM,10367288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD YUKON CNTAD OCT 3.5X45MM,10367289,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD YUKON CNTAD OCT 3.5X45MM,10367289,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR YUKON TRANS 60MM,10367290,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR YUKON TRANS 60MM,10367290,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HOOK YUKON TRANS CONNECTOR,10367291,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HOOK YUKON TRANS CONNECTOR,10367291,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE POS FEM AUG SZ 8 4MM,10367292,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE POS FEM AUG SZ 8 4MM,10367292,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS RP INSRT SZ 8 8MM,10367293,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS RP INSRT SZ 8 8MM,10367293,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MED 0D MTP RT 2.4-2.7X52,10367295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7049.00,2114.70,2735.01,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2735.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5991.65,,,percent of total billed charges,,,3172.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MED 0D MTP RT 2.4-2.7X52,10367295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7049.00,2114.70,2960.58,5991.65,,3454.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2960.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3555.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2995.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5991.65,,,percent of total billed charges,,,3242.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR RP SZ7 8MM,10367296,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR RP SZ7 8MM,10367296,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HMRL VERSADL 38X19X39MM,10367297,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4380.00,1314.00,1699.44,3723.0,,,,,,,,,,,,,,,,,,,,1699.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3723.0,,,percent of total billed charges,,,1971.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HMRL VERSADL 38X19X39MM,10367297,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4380.00,1314.00,1861.5,3723.0,,,,,,,,,,,,,service not payable,,,,,,,2209.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1861.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3285.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2190.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3285.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3723.0,,,percent of total billed charges,,,2014.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB RT 8,10367298,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB RT 8,10367298,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB RT 4,10367299,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB RT 4,10367299,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR SZ8 8MM X_1516-20-808 X_DEPUY,10367300,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR SZ8 8MM X_1516-20-808 X_DEPUY,10367300,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH AND STARTER PLEURX,10367305,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,2026.42,,,percent of total billed charges,,,,,,,,service not payable,1600.15,,,percent of total billed charges,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH and STARTER PERITONEAL,10367306,CDM,0272,RC,C1752,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,2026.42,,,percent of total billed charges,,,,,,,,service not payable,1600.15,,,percent of total billed charges,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2131.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SEALANT DURA,10367415,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,21721.00,6516.30,8427.75,18462.85,,10643.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9122.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8427.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9231.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10860.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18462.85,,,percent of total billed charges,,,9774.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SEALANT DURA,10367415,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,21721.00,6516.30,9122.82,18462.85,,10643.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9122.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10956.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9231.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16290.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10860.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16290.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18462.85,,,percent of total billed charges,,,9991.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 127D SZ2 23MM,10367416,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 127D SZ2 23MM,10367416,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TRIT SOLIDBACK 56F,10367417,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRIT SOLIDBACK 56F,10367417,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SUPERCONDYLAR 10X320MM,10367418,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6041.00,1812.30,2343.91,5134.85,,2960.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2537.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2343.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2567.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4530.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5134.85,,,percent of total billed charges,,,2718.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SUPERCONDYLAR 10X320MM,10367418,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6041.00,1812.30,2537.22,5134.85,,2960.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2537.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3047.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2567.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4530.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4530.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5134.85,,,percent of total billed charges,,,2778.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MESA 6.5X55MM,10367420,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MESA 6.5X55MM,10367420,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MESA 6.5X50MM,10367421,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MESA 6.5X50MM,10367421,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 9,10367422,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 9,10367422,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI NL 4.5X26MM,10367423,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI NL 4.5X26MM,10367423,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMAX W/INST 25WX20L,10367640,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8180.00,2454.00,3173.84,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3173.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6953.0,,,percent of total billed charges,,,3681.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMAX W/INST 25WX20L,10367640,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8180.00,2454.00,3435.60,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4125.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6953.0,,,percent of total billed charges,,,3762.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT GELWEAVE ST 34MMX60CM,10367641,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2234.00,670.20,866.79,1898.90,,,,,,,,,,,,,,,,,,,,866.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1675.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1898.90,,,percent of total billed charges,,,1005.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT GELWEAVE ST 34MMX60CM,10367641,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2234.00,670.20,949.45,1898.90,,,,,,,,,,,,,service not payable,,,,,,,1126.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,949.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1675.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1117.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1675.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1898.90,,,percent of total billed charges,,,1027.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOC AKREOS AO 22.0,10367646,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 22.0,10367646,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH FOLEY FOLYSIL 14F 10CC,10367650,CDM,0272,RC,A4346,HCPCS,,,,,,outpatient,facility,,,41.00,12.30,17.43,34.85,,25.34,,,percent of total billed charges,,,,,,,,service not payable,20.01,,,percent of total billed charges,,,20.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17.43,,,percent of total billed charges,,,,,,,,,30.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20.5,,,percent of total billed charges,,,,,,,,service not payable,30.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34.85,,,percent of total billed charges,,,18.86,,,percent of total billed charges,,,,,,,,,26.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,26.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH FOLEY LUBRICATH 30CC 20F,10367651,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,66.00,19.80,28.05,56.10,,40.79,,,percent of total billed charges,,,,,,,,service not payable,32.21,,,percent of total billed charges,,,33.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,42.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,42.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS MENISCAL ROOT REPAIR X_7193-5068 X_SMITH NEPHE,10367652,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS MENISCAL ROOT REPAIR X_7193-5068 X_SMITH NEPHE,10367652,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP HEADLESS 3.5X40MM,10367653,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP HEADLESS 3.5X40MM,10367653,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS FEMORAL RT SZ 6 CEM,10367654,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEMORAL RT SZ 6 CEM,10367654,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CONDYLE LT SZ 4,10367655,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CONDYLE LT SZ 4,10367655,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR RT SZ 3-4 1MM,10367656,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR RT SZ 3-4 1MM,10367656,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 67.5 LT,10367657,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 67.5 LT,10367657,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BRG TIB PS 14X79/83,10367658,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRG TIB PS 14X79/83,10367658,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CROSSTELLA R2P 2X100MM,10367659,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1973.00,591.90,838.52,1677.05,,1219.31,,,percent of total billed charges,,,,,,,,service not payable,962.82,,,percent of total billed charges,,,995.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.52,,,percent of total billed charges,,,,,,,,,1479.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,986.5,,,percent of total billed charges,,,,,,,,service not payable,1479.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.05,,,percent of total billed charges,,,907.58,,,percent of total billed charges,,,,,,,,,1282.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1282.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT SE PERI 200CM 6F 7MMX60M,10367660,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT SE PERI 200CM 6F 7MMX60M,10367660,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 BEIGE SZ 2,10367662,CDM,0272,RC,A6536,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,42.16,190.40,,138.43,,,percent of total billed charges,,,,,,,,service not payable,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,service not payable,168.0,,,percent of total billed charges,,,42.16,,,fee schedule,,,,,,,,service not payable,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,145.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 3 X 4CM,10367667,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,7504.00,2251.20,2911.55,6378.40,,3676.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3151.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2911.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3189.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5628.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3752.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6378.40,,,percent of total billed charges,,,3376.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 3 X 4CM,10367667,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,7504.00,2251.20,3151.68,6378.40,,3676.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3151.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3785.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3189.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5628.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3752.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5628.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6378.40,,,percent of total billed charges,,,3451.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT TOE 2 15MM,10367669,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2772.00,831.60,1075.54,2356.20,,,,,,,,,,,,,,,,,,,,1075.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1178.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2079.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1386.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2356.20,,,percent of total billed charges,,,1247.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT TOE 2 15MM,10367669,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2772.00,831.60,1178.10,2356.20,,,,,,,,,,,,,service not payable,,,,,,,1398.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1178.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2079.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1386.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2079.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2356.20,,,percent of total billed charges,,,1275.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH RXG 1.0 PROFILE 51.2MM,10367670,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3694.00,1108.20,1433.27,3139.90,,,,,,,,,,,,,,,,,,,,1433.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2770.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1847.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3139.90,,,percent of total billed charges,,,1662.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH RXG 1.0 PROFILE 51.2MM,10367670,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3694.00,1108.20,1569.95,3139.90,,,,,,,,,,,,,service not payable,,,,,,,1863.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1569.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2770.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1847.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2770.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3139.90,,,percent of total billed charges,,,1699.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACE AVS UNLIF 4D 8X9X20MM,10367671,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACE AVS UNLIF 4D 8X9X20MM,10367671,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 335CC,10367672,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 335CC,10367672,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 600CC,10367673,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 600CC,10367673,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 695CC,10367674,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 695CC,10367674,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 745CC,10367675,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 745CC,10367675,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 110CC,10367676,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 110CC,10367676,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 125CC,10367677,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 125CC,10367677,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 125CC,10367678,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 125CC,10367678,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 145CC,10367679,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 145CC,10367679,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 2.1X8MM,10367686,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,224.00,67.20,86.91,190.40,,,,,,,,,,,,,,,,,,,,86.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,100.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 2.1X8MM,10367686,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,,,,,,,,,,,,service not payable,,,,,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,112.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,168.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 2.1X10MM,10367687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,224.00,67.20,86.91,190.40,,,,,,,,,,,,,,,,,,,,86.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,168.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.40,,,percent of total billed charges,,,100.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 2.1X10MM,10367687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,95.20,190.40,,,,,,,,,,,,,service not payable,,,,,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,112.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,168.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONTOURED 5.5X70MM,10367688,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONTOURED 5.5X70MM,10367688,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 20.0 D 6MM,10367690,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 20.0 D 6MM,10367690,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Helicobacter pylori Stool Antigen - MH/WH/JE,10367978,CDM,0300,RC,87338,CPT,,,,,,outpatient,facility,,,77.00,23.10,13.66,65.45,,61.11,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.09,,,fee schedule,,,45.60,,,fee schedule,,,29.99,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,29.77,,,fee schedule,,,13.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.37,,,fee schedule,,,32.5,,,fee schedule,,,,,,,,,14.09,,,fee schedule,,,,,,,,,18.53,,,fee schedule,,,29.34,,,fee schedule,,,57.75,,,percent of total billed charges,,,14.09,,,fee schedule,,,13.66,,,fee schedule,,,14.37,,,fee schedule,,,21.80,,,fee schedule,,,14.09,,,fee schedule,,,57.75,,,percent of total billed charges,,,,,,,,,14.37,,,fee schedule,,,,,,,,,65.45,,,percent of total billed charges,,,35.42,,,percent of total billed charges,,,,,,,,,15.82,,,fee schedule,,,14.09,,,fee schedule,,,,,,,,,13.95,,,fee schedule,,,14.09,,,fee schedule,,,,,,,,,14.23,,,fee schedule,,,,,,,,
Helicobacter pylori Stool Antigen - MH/WH/JE,10367978,CDM,0300,RC,87338,CPT,396,EAPG,,,,outpatient,facility,,,77.00,23.10,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Aspiration of joint wrist elbow or ankle,10368350,CDM,0761,RC,20605,CPT,,,,,,outpatient,facility,,,693.00,207.90,118.0,589.05,,428.27,,,percent of total billed charges,,,,,,,,,338.18,,,percent of total billed charges,,,349.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.52,,,percent of total billed charges,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,346.5,,,percent of total billed charges,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,589.05,,,percent of total billed charges,,,318.78,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Aspiration of joint wrist elbow or ankle,10368350,CDM,0761,RC,20605,CPT,05441,APC,,,,outpatient,facility,,,693.00,207.90,271.53,650.16,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,595.5,,,fee schedule,,,271.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",288.74,,,fee schedule,,,650.16,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,586.87,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,271.53,,,fee schedule,,,288.74,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,271.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",288.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,285.90,,,fee schedule,,,,,,,,
WC-Aspiration of joint wrist elbow or ankle,10368350,CDM,0761,RC,20605,CPT,49,EAPG,,,,outpatient,facility,,,693.00,207.90,358.17,1009.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1009.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,857.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,358.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,358.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,600.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,660.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL ACET TRIT SOLIDBACK 58F,10368419,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRIT SOLIDBACK 58F,10368419,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 3 11MM KNEE,10368420,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 3 11MM KNEE,10368420,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA 4X30MM,10368422,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA 4X30MM,10368422,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA 4X28MM,10368423,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA 4X28MM,10368423,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINAL CERV POST 3.5X120MM,10368424,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINAL CERV POST 3.5X120MM,10368424,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 4 10MM,10368425,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 4 10MM,10368425,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE SERRATO 7.5X50MM,10368427,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE SERRATO 7.5X50MM,10368427,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT AORTIC 14F 36X36X49MM,10368428,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13793.00,4137.90,5351.68,11724.05,,6758.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5793.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5351.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5862.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10344.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6896.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11724.05,,,percent of total billed charges,,,6206.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT AORTIC 14F 36X36X49MM,10368428,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13793.00,4137.90,5793.06,11724.05,,6758.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5793.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6957.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5862.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10344.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6896.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10344.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11724.05,,,percent of total billed charges,,,6344.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIATRAC 14PPD 5X15X135,10368429,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIATRAC 14PPD 6.5X15X135,10368430,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIATRAC 14PPD 7X15X135,10368431,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM STR 8INCH 15.0 SM,10368432,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,28328.00,8498.40,10991.26,24078.80,,13880.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11897.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10991.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12039.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24078.80,,,percent of total billed charges,,,12747.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM STR 8INCH 15.0 SM,10368432,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,28328.00,8498.40,11897.76,24078.80,,13880.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11897.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14288.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12039.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24078.80,,,percent of total billed charges,,,13030.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 SZ5 9MM,10368434,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 SZ5 9MM,10368434,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Phrenic Nerve Injection,10368563,CDM,0761,RC,64999,CPT,,,,,,outpatient,facility,,,1368.00,410.40,118.0,1162.8,,845.42,,,percent of total billed charges,,,,,,,,,667.58,,,percent of total billed charges,,,690.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,581.40,,,percent of total billed charges,,,,,,,,,1026.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,684.0,,,percent of total billed charges,,,,,,,,,1026.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1162.8,,,percent of total billed charges,,,629.28,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Phrenic Nerve Injection,10368563,CDM,0761,RC,64999,CPT,05441,APC,,,,outpatient,facility,,,1368.00,410.40,271.53,650.16,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,595.5,,,fee schedule,,,271.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",288.74,,,fee schedule,,,650.16,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,586.87,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,271.53,,,fee schedule,,,288.74,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,271.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",288.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,285.90,,,fee schedule,,,,,,,,
Phrenic Nerve Injection,10368563,CDM,0761,RC,64999,CPT,214,EAPG,,,,outpatient,facility,,,1368.00,410.40,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Biofeedback 1st 15 min - OT,10368705,CDM,0430,RC,90912,CPT,,,,,GO  ,outpatient,facility,,,141.00,42.30,61.01,260.0,,87.14,,,percent of total billed charges,,,71.65,,,fee schedule,,,68.81,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,150.74,,,fee schedule,,,61.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",73.07,,,fee schedule,,,164.55,,,fee schedule,,,,,,,,,71.64,,,fee schedule,,,,,,,,,173.0,,,per diem,,,148.55,,,fee schedule,,,105.75,,,percent of total billed charges,,,71.65,,,fee schedule,,,61.01,,,fee schedule,,,73.08,,,fee schedule,,,204.0,,,per diem,,,71.64,,,fee schedule,,,105.75,,,percent of total billed charges,,,61.01,,,fee schedule,,,73.08,,,fee schedule,,,,,,,,,119.85,,,percent of total billed charges,,,64.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,71.64,,,fee schedule,,,,,,,,,229.0,,,per diem,,,71.65,,,fee schedule,,,,,,,,,71.65,,,fee schedule,,,,,,,,
Biofeedback 1st 15 min - OT,10368705,CDM,0430,RC,90912,CPT,427,EAPG,,,GO  ,outpatient,facility,,,141.00,42.30,128.18,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Biofeedback ea addl 15 min - OT,10368706,CDM,0430,RC,90913,CPT,,,,,GO  ,outpatient,facility,,,78.00,23.40,29.05,260.0,,48.20,,,percent of total billed charges,,,29.14,,,fee schedule,,,38.06,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,61.29,,,fee schedule,,,61.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",29.63,,,fee schedule,,,66.72,,,fee schedule,,,,,,,,,29.05,,,fee schedule,,,,,,,,,173.0,,,per diem,,,60.40,,,fee schedule,,,58.5,,,percent of total billed charges,,,29.14,,,fee schedule,,,61.01,,,fee schedule,,,29.72,,,fee schedule,,,204.0,,,per diem,,,29.05,,,fee schedule,,,58.5,,,percent of total billed charges,,,61.01,,,fee schedule,,,29.72,,,fee schedule,,,,,,,,,66.30,,,percent of total billed charges,,,35.88,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.05,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.14,,,fee schedule,,,,,,,,,29.14,,,fee schedule,,,,,,,,
Biofeedback ea addl 15 min - OT,10368706,CDM,0430,RC,90913,CPT,427,EAPG,,,GO  ,outpatient,facility,,,78.00,23.40,78.0,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
THER IVNTJ 1ST 15 MIN - OT,10368707,CDM,0430,RC,97129,CPT,,,,,GO  ,outpatient,facility,,,196.00,58.80,20.68,260.0,,121.13,,,percent of total billed charges,,,20.71,,,fee schedule,,,96.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,43.57,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.09,,,fee schedule,,,47.51,,,fee schedule,,,,,,,,,20.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,42.94,,,fee schedule,,,147.0,,,percent of total billed charges,,,20.71,,,fee schedule,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,204.0,,,per diem,,,20.68,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,20.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,20.71,,,fee schedule,,,,,,,,,20.71,,,fee schedule,,,,,,,,
THER IVNTJ 1ST 15 MIN - OT,10368707,CDM,0430,RC,97129,CPT,269,EAPG,,,GO  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ther IVNTJ each addtl 15 min - OT,10368708,CDM,0430,RC,97130,CPT,,,,,GO  ,outpatient,facility,,,196.00,58.80,19.75,260.0,,121.13,,,percent of total billed charges,,,19.78,,,fee schedule,,,96.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,41.61,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.14,,,fee schedule,,,45.36,,,fee schedule,,,,,,,,,19.75,,,fee schedule,,,,,,,,,173.0,,,per diem,,,41.0,,,fee schedule,,,147.0,,,percent of total billed charges,,,19.78,,,fee schedule,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,204.0,,,per diem,,,19.75,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,19.75,,,fee schedule,,,,,,,,,229.0,,,per diem,,,19.78,,,fee schedule,,,,,,,,,19.78,,,fee schedule,,,,,,,,
Ther IVNTJ each addtl 15 min - OT,10368708,CDM,0430,RC,97130,CPT,269,EAPG,,,GO  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Biofeedback 1st 15 min - PT,10368735,CDM,0420,RC,90912,CPT,,,,,GP  ,outpatient,facility,,,141.00,42.30,61.01,260.0,,87.14,,,percent of total billed charges,,,71.65,,,fee schedule,,,68.81,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,150.74,,,fee schedule,,,61.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",73.07,,,fee schedule,,,164.55,,,fee schedule,,,,,,,,,71.64,,,fee schedule,,,,,,,,,173.0,,,per diem,,,148.55,,,fee schedule,,,105.75,,,percent of total billed charges,,,71.65,,,fee schedule,,,61.01,,,fee schedule,,,73.08,,,fee schedule,,,204.0,,,per diem,,,71.64,,,fee schedule,,,105.75,,,percent of total billed charges,,,61.01,,,fee schedule,,,73.08,,,fee schedule,,,,,,,,,119.85,,,percent of total billed charges,,,64.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,71.64,,,fee schedule,,,,,,,,,229.0,,,per diem,,,71.65,,,fee schedule,,,,,,,,,71.65,,,fee schedule,,,,,,,,
Biofeedback 1st 15 min - PT,10368735,CDM,0420,RC,90912,CPT,427,EAPG,,,GP  ,outpatient,facility,,,141.00,42.30,128.18,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Biofeedback ea addl 15 min - PT,10368736,CDM,0420,RC,90913,CPT,,,,,GP  ,outpatient,facility,,,78.00,23.40,29.05,260.0,,48.20,,,percent of total billed charges,,,29.14,,,fee schedule,,,38.06,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,61.29,,,fee schedule,,,61.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",29.63,,,fee schedule,,,66.72,,,fee schedule,,,,,,,,,29.05,,,fee schedule,,,,,,,,,173.0,,,per diem,,,60.40,,,fee schedule,,,58.5,,,percent of total billed charges,,,29.14,,,fee schedule,,,61.01,,,fee schedule,,,29.72,,,fee schedule,,,204.0,,,per diem,,,29.05,,,fee schedule,,,58.5,,,percent of total billed charges,,,61.01,,,fee schedule,,,29.72,,,fee schedule,,,,,,,,,66.30,,,percent of total billed charges,,,35.88,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.05,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.14,,,fee schedule,,,,,,,,,29.14,,,fee schedule,,,,,,,,
Biofeedback ea addl 15 min - PT,10368736,CDM,0420,RC,90913,CPT,427,EAPG,,,GP  ,outpatient,facility,,,78.00,23.40,78.0,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
THER IVNTJ 1ST 15 MIN - PT,10368737,CDM,0420,RC,97129,CPT,,,,,GP  ,outpatient,facility,,,196.00,58.80,20.68,260.0,,121.13,,,percent of total billed charges,,,20.71,,,fee schedule,,,96.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,43.57,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.09,,,fee schedule,,,47.51,,,fee schedule,,,,,,,,,20.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,42.94,,,fee schedule,,,147.0,,,percent of total billed charges,,,20.71,,,fee schedule,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,204.0,,,per diem,,,20.68,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,20.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,20.71,,,fee schedule,,,,,,,,,20.71,,,fee schedule,,,,,,,,
THER IVNTJ 1ST 15 MIN - PT,10368737,CDM,0420,RC,97129,CPT,269,EAPG,,,GP  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ther IVNTJ each addtl 15 min - PT,10368738,CDM,0420,RC,97130,CPT,,,,,GP  ,outpatient,facility,,,196.00,58.80,19.75,260.0,,121.13,,,percent of total billed charges,,,19.78,,,fee schedule,,,96.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,41.61,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.14,,,fee schedule,,,45.36,,,fee schedule,,,,,,,,,19.75,,,fee schedule,,,,,,,,,173.0,,,per diem,,,41.0,,,fee schedule,,,147.0,,,percent of total billed charges,,,19.78,,,fee schedule,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,204.0,,,per diem,,,19.75,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,19.75,,,fee schedule,,,,,,,,,229.0,,,per diem,,,19.78,,,fee schedule,,,,,,,,,19.78,,,fee schedule,,,,,,,,
Ther IVNTJ each addtl 15 min - PT,10368738,CDM,0420,RC,97130,CPT,269,EAPG,,,GP  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ther IVNTJ for Cognitive Function 1ST 15 min - ST,10368756,CDM,0440,RC,97129,CPT,,,,,GN  ,outpatient,facility,,,196.00,58.80,20.68,260.0,,121.13,,,percent of total billed charges,,,20.71,,,fee schedule,,,96.43,,,fee schedule,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,43.57,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.09,,,fee schedule,,,47.51,,,fee schedule,,,,,,,,,20.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,42.94,,,fee schedule,,,147.0,,,percent of total billed charges,,,20.71,,,fee schedule,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,204.0,,,per diem,,,20.68,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,20.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,20.71,,,fee schedule,,,,,,,,,20.71,,,fee schedule,,,,,,,,
Ther IVNTJ for Cognitive Function 1ST 15 min - ST,10368756,CDM,0440,RC,97129,CPT,269,EAPG,,,GN  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Ther IVNTJ each addtl 15 min - ST,10368757,CDM,0440,RC,97130,CPT,,,,,GN  ,outpatient,facility,,,196.00,58.80,19.75,260.0,,121.13,,,percent of total billed charges,,,19.78,,,fee schedule,,,96.43,,,fee schedule,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,41.61,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.14,,,fee schedule,,,45.36,,,fee schedule,,,,,,,,,19.75,,,fee schedule,,,,,,,,,173.0,,,per diem,,,41.0,,,fee schedule,,,147.0,,,percent of total billed charges,,,19.78,,,fee schedule,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,204.0,,,per diem,,,19.75,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,19.75,,,fee schedule,,,,,,,,,229.0,,,per diem,,,19.78,,,fee schedule,,,,,,,,,19.78,,,fee schedule,,,,,,,,
Ther IVNTJ each addtl 15 min - ST,10368757,CDM,0440,RC,97130,CPT,269,EAPG,,,GN  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-Phrenic Nerve Injection.,10368774,CDM,0761,RC,64999,CPT,,,,,,outpatient,facility,,,1410.00,423.00,118.0,1198.5,,871.38,,,percent of total billed charges,,,,,,,,,688.08,,,percent of total billed charges,,,711.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,,,,,,,1057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,705.0,,,percent of total billed charges,,,,,,,,,1057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1198.5,,,percent of total billed charges,,,648.60,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC-Phrenic Nerve Injection.,10368774,CDM,0761,RC,64999,CPT,05441,APC,,,,outpatient,facility,,,1410.00,423.00,271.53,650.16,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,595.5,,,fee schedule,,,271.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",288.74,,,fee schedule,,,650.16,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,586.87,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,271.53,,,fee schedule,,,288.74,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,271.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",288.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,285.90,,,fee schedule,,,,,,,,
PMC-Phrenic Nerve Injection.,10368774,CDM,0761,RC,64999,CPT,214,EAPG,,,,outpatient,facility,,,1410.00,423.00,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-NJX AAand/STRD NRV NRVTG SI JT,10368775,CDM,0761,RC,64451,CPT,,,,,,outpatient,facility,,,1961.00,588.30,118.0,1666.85,,1211.90,,,percent of total billed charges,,,,,,,,,956.97,,,percent of total billed charges,,,989.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.42,,,percent of total billed charges,,,,,,,,,1470.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,980.5,,,percent of total billed charges,,,,,,,,,1470.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1666.85,,,percent of total billed charges,,,902.06,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC-NJX AAand/STRD NRV NRVTG SI JT,10368775,CDM,0761,RC,64451,CPT,05442,APC,,,,outpatient,facility,,,1961.00,588.30,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
PMC-NJX AAand/STRD NRV NRVTG SI JT,10368775,CDM,0761,RC,64451,CPT,220,EAPG,,,,outpatient,facility,,,1961.00,588.30,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC- NJX AAand/STRD GNCLR NRV BRNCH,10368776,CDM,0761,RC,64454,CPT,,,,,,outpatient,facility,,,1961.00,588.30,118.0,1666.85,,1211.90,,,percent of total billed charges,,,,,,,,,956.97,,,percent of total billed charges,,,989.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.42,,,percent of total billed charges,,,,,,,,,1470.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,980.5,,,percent of total billed charges,,,,,,,,,1470.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1666.85,,,percent of total billed charges,,,902.06,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC- NJX AAand/STRD GNCLR NRV BRNCH,10368776,CDM,0761,RC,64454,CPT,05442,APC,,,,outpatient,facility,,,1961.00,588.30,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
PMC- NJX AAand/STRD GNCLR NRV BRNCH,10368776,CDM,0761,RC,64454,CPT,214,EAPG,,,,outpatient,facility,,,1961.00,588.30,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-DSTRJ NULYT AGT GNCLR NRV,10368777,CDM,0761,RC,64624,CPT,,,,,,outpatient,facility,,,5393.00,1617.90,118.0,4584.05,,3332.87,,,percent of total billed charges,,,,,,,,,2631.78,,,percent of total billed charges,,,2720.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.03,,,percent of total billed charges,,,,,,,,,4044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2696.5,,,percent of total billed charges,,,,,,,,,4044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4584.05,,,percent of total billed charges,,,2480.78,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC-DSTRJ NULYT AGT GNCLR NRV,10368777,CDM,0761,RC,64624,CPT,05431,APC,,,,outpatient,facility,,,5393.00,1617.90,1872.64,4300.98,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,3939.40,,,fee schedule,,,,,,,,,1910.09,,,fee schedule,,,4300.98,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,3882.30,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,1910.09,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,1910.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,1891.29,,,fee schedule,,,,,,,,
PMC-DSTRJ NULYT AGT GNCLR NRV,10368777,CDM,0761,RC,64624,CPT,220,EAPG,,,,outpatient,facility,,,5393.00,1617.90,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-RF ABLTJ NRV NRVTG SI JT,10368778,CDM,0761,RC,64625,CPT,,,,,,outpatient,facility,,,5393.00,1617.90,118.0,4584.05,,3332.87,,,percent of total billed charges,,,,,,,,,2631.78,,,percent of total billed charges,,,2720.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.03,,,percent of total billed charges,,,,,,,,,4044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2696.5,,,percent of total billed charges,,,,,,,,,4044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4584.05,,,percent of total billed charges,,,2480.78,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC-RF ABLTJ NRV NRVTG SI JT,10368778,CDM,0761,RC,64625,CPT,05431,APC,,,,outpatient,facility,,,5393.00,1617.90,1872.64,4300.98,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,3939.40,,,fee schedule,,,,,,,,,1910.09,,,fee schedule,,,4300.98,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,3882.30,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,1910.09,,,fee schedule,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,1910.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,,,,,,,1872.64,,,fee schedule,,,,,,,,,1891.29,,,fee schedule,,,,,,,,
PMC-RF ABLTJ NRV NRVTG SI JT,10368778,CDM,0761,RC,64625,CPT,217,EAPG,,,,outpatient,facility,,,5393.00,1617.90,1958.90,4426.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4426.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3762.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1958.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1958.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1958.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2829.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3112.65,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-NDL INSJ W/O NJX 1 OR 2 MUSC,10368779,CDM,0761,RC,20560,CPT,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,137.0,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC-NDL INSJ W/O NJX 1 OR 2 MUSC,10368779,CDM,0761,RC,20560,CPT,05731,APC,,,,outpatient,facility,,,274.00,82.20,23.49,53.95,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,49.41,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,53.95,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,48.69,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.72,,,fee schedule,,,,,,,,
PMC-NDL INSJ W/O NJX 1 OR 2 MUSC,10368779,CDM,0761,RC,20560,CPT,493,EAPG,,,,outpatient,facility,,,274.00,82.20,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-NDL INSJ W/O NJX 3 MUSC,10368780,CDM,0761,RC,20561,CPT,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,137.0,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PMC-NDL INSJ W/O NJX 3 MUSC,10368780,CDM,0761,RC,20561,CPT,05731,APC,,,,outpatient,facility,,,274.00,82.20,23.49,53.95,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,49.41,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,53.95,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,48.69,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.72,,,fee schedule,,,,,,,,
PMC-NDL INSJ W/O NJX 3 MUSC,10368780,CDM,0761,RC,20561,CPT,493,EAPG,,,,outpatient,facility,,,274.00,82.20,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG CONT REC W/VID EEG TECH,10368793,CDM,0740,RC,95700,CPT,,,,,,outpatient,facility,,,794.00,238.20,337.45,726.0,,490.69,,,percent of total billed charges,,,,,,,,,387.47,,,percent of total billed charges,,,400.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,397.0,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.90,,,percent of total billed charges,,,365.24,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG CONT REC W/VID EEG TECH,10368793,CDM,0740,RC,95700,CPT,05721,APC,,,,outpatient,facility,,,794.00,238.20,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
NER-EEG CONT REC W/VID EEG TECH,10368793,CDM,0740,RC,95700,CPT,211,EAPG,,,,outpatient,facility,,,794.00,238.20,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG W/O VID 2-12 HR UNMNTR,10368794,CDM,0740,RC,95705,CPT,,,,,,outpatient,facility,,,794.00,238.20,337.45,726.0,,490.69,,,percent of total billed charges,,,,,,,,,387.47,,,percent of total billed charges,,,400.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,397.0,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.90,,,percent of total billed charges,,,365.24,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG W/O VID 2-12 HR UNMNTR,10368794,CDM,0740,RC,95705,CPT,05722,APC,,,,outpatient,facility,,,794.00,238.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-EEG W/O VID 2-12 HR UNMNTR,10368794,CDM,0740,RC,95705,CPT,211,EAPG,,,,outpatient,facility,,,794.00,238.20,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG WO VID 2-12HR INTMT MNTR,10368795,CDM,0740,RC,95706,CPT,,,,,,outpatient,facility,,,794.00,238.20,337.45,726.0,,490.69,,,percent of total billed charges,,,,,,,,,387.47,,,percent of total billed charges,,,400.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,397.0,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.90,,,percent of total billed charges,,,365.24,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG WO VID 2-12HR INTMT MNTR,10368795,CDM,0740,RC,95706,CPT,05722,APC,,,,outpatient,facility,,,794.00,238.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-EEG WO VID 2-12HR INTMT MNTR,10368795,CDM,0740,RC,95706,CPT,211,EAPG,,,,outpatient,facility,,,794.00,238.20,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG W/O VID 2-12HR CONT MNTR,10368796,CDM,0740,RC,95706,CPT,,,,,,outpatient,facility,,,794.00,238.20,337.45,726.0,,490.69,,,percent of total billed charges,,,,,,,,,387.47,,,percent of total billed charges,,,400.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,397.0,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.90,,,percent of total billed charges,,,365.24,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG W/O VID 2-12HR CONT MNTR,10368796,CDM,0740,RC,95706,CPT,05722,APC,,,,outpatient,facility,,,794.00,238.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-EEG W/O VID 2-12HR CONT MNTR,10368796,CDM,0740,RC,95706,CPT,211,EAPG,,,,outpatient,facility,,,794.00,238.20,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG WO VID EA 12-26HR UNMNTR,10368797,CDM,0740,RC,95708,CPT,,,,,,outpatient,facility,,,1522.00,456.60,639.0,1293.7,,940.60,,,percent of total billed charges,,,,,,,,,742.74,,,percent of total billed charges,,,767.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.85,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.0,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1293.7,,,percent of total billed charges,,,700.12,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG WO VID EA 12-26HR UNMNTR,10368797,CDM,0740,RC,95708,CPT,05723,APC,,,,outpatient,facility,,,1522.00,456.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
NER-EEG WO VID EA 12-26HR UNMNTR,10368797,CDM,0740,RC,95708,CPT,210,EAPG,,,,outpatient,facility,,,1522.00,456.60,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG W/O VID EA 12-26HR INTMT,10368798,CDM,0740,RC,95709,CPT,,,,,,outpatient,facility,,,1522.00,456.60,639.0,1293.7,,940.60,,,percent of total billed charges,,,,,,,,,742.74,,,percent of total billed charges,,,767.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.85,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.0,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1293.7,,,percent of total billed charges,,,700.12,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG W/O VID EA 12-26HR INTMT,10368798,CDM,0740,RC,95709,CPT,05723,APC,,,,outpatient,facility,,,1522.00,456.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
NER-EEG W/O VID EA 12-26HR INTMT,10368798,CDM,0740,RC,95709,CPT,210,EAPG,,,,outpatient,facility,,,1522.00,456.60,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG W/O VID EA 12-26HR CONT,10368799,CDM,0740,RC,95710,CPT,,,,,,outpatient,facility,,,1522.00,456.60,639.0,1293.7,,940.60,,,percent of total billed charges,,,,,,,,,742.74,,,percent of total billed charges,,,767.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.85,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.0,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1293.7,,,percent of total billed charges,,,700.12,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-EEG W/O VID EA 12-26HR CONT,10368799,CDM,0740,RC,95710,CPT,05723,APC,,,,outpatient,facility,,,1522.00,456.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
NER-EEG W/O VID EA 12-26HR CONT,10368799,CDM,0740,RC,95710,CPT,210,EAPG,,,,outpatient,facility,,,1522.00,456.60,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-VEEG 2-12 HR UNMONITORED,10368800,CDM,0740,RC,95711,CPT,,,,,,outpatient,facility,,,794.00,238.20,337.45,726.0,,490.69,,,percent of total billed charges,,,,,,,,,387.47,,,percent of total billed charges,,,400.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,397.0,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.90,,,percent of total billed charges,,,365.24,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-VEEG 2-12 HR UNMONITORED,10368800,CDM,0740,RC,95711,CPT,05722,APC,,,,outpatient,facility,,,794.00,238.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-VEEG 2-12 HR UNMONITORED,10368800,CDM,0740,RC,95711,CPT,211,EAPG,,,,outpatient,facility,,,794.00,238.20,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-VEEG 2-12 HR INTMT MNTR,10368801,CDM,0740,RC,95712,CPT,,,,,,outpatient,facility,,,794.00,238.20,337.45,726.0,,490.69,,,percent of total billed charges,,,,,,,,,387.47,,,percent of total billed charges,,,400.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.45,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,397.0,,,percent of total billed charges,,,,,,,,,595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.90,,,percent of total billed charges,,,365.24,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-VEEG 2-12 HR INTMT MNTR,10368801,CDM,0740,RC,95712,CPT,05722,APC,,,,outpatient,facility,,,794.00,238.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
NER-VEEG 2-12 HR INTMT MNTR,10368801,CDM,0740,RC,95712,CPT,211,EAPG,,,,outpatient,facility,,,794.00,238.20,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-VEEG 2-12 HR CONT MNTR,10368802,CDM,0740,RC,95713,CPT,,,,,,outpatient,facility,,,1522.00,456.60,639.0,1293.7,,940.60,,,percent of total billed charges,,,,,,,,,742.74,,,percent of total billed charges,,,767.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.85,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.0,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1293.7,,,percent of total billed charges,,,700.12,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-VEEG 2-12 HR CONT MNTR,10368802,CDM,0740,RC,95713,CPT,05723,APC,,,,outpatient,facility,,,1522.00,456.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
NER-VEEG 2-12 HR CONT MNTR,10368802,CDM,0740,RC,95713,CPT,211,EAPG,,,,outpatient,facility,,,1522.00,456.60,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-VEEG EA 12-26 HR UNMNTR,10368803,CDM,0740,RC,95714,CPT,,,,,,outpatient,facility,,,1522.00,456.60,639.0,1293.7,,940.60,,,percent of total billed charges,,,,,,,,,742.74,,,percent of total billed charges,,,767.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.85,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.0,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1293.7,,,percent of total billed charges,,,700.12,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-VEEG EA 12-26 HR UNMNTR,10368803,CDM,0740,RC,95714,CPT,05723,APC,,,,outpatient,facility,,,1522.00,456.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
NER-VEEG EA 12-26 HR UNMNTR,10368803,CDM,0740,RC,95714,CPT,210,EAPG,,,,outpatient,facility,,,1522.00,456.60,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-VEEG EA 12-26HR INTMT MNTR,10368804,CDM,0740,RC,95715,CPT,,,,,,outpatient,facility,,,1522.00,456.60,639.0,1293.7,,940.60,,,percent of total billed charges,,,,,,,,,742.74,,,percent of total billed charges,,,767.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.85,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.0,,,percent of total billed charges,,,,,,,,,1141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1293.7,,,percent of total billed charges,,,700.12,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-VEEG EA 12-26HR INTMT MNTR,10368804,CDM,0740,RC,95715,CPT,05723,APC,,,,outpatient,facility,,,1522.00,456.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
NER-VEEG EA 12-26HR INTMT MNTR,10368804,CDM,0740,RC,95715,CPT,210,EAPG,,,,outpatient,facility,,,1522.00,456.60,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-VEEG EA 12-26HR CONT MNTR,10368805,CDM,0740,RC,95716,CPT,,,,,,outpatient,facility,,,2852.00,855.60,639.0,2424.20,,1762.54,,,percent of total billed charges,,,,,,,,,1391.78,,,percent of total billed charges,,,1438.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1212.10,,,percent of total billed charges,,,,,,,,,2139.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1426.0,,,percent of total billed charges,,,,,,,,,2139.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2424.20,,,percent of total billed charges,,,1311.92,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,,,,,,,,639.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
NER-VEEG EA 12-26HR CONT MNTR,10368805,CDM,0740,RC,95716,CPT,05724,APC,,,,outpatient,facility,,,2852.00,855.60,935.82,2240.81,,,,,,,,975.65,,,fee schedule,,,,,,,,,,,,,,,2052.43,,,fee schedule,,,935.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",995.16,,,fee schedule,,,2240.81,,,fee schedule,,,,,,,,,975.65,,,fee schedule,,,,,,,,,,,,,,,2022.68,,,fee schedule,,,,,,,,,975.65,,,fee schedule,,,935.82,,,fee schedule,,,995.16,,,fee schedule,,,,,,,,,975.65,,,fee schedule,,,,,,,,,935.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",995.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.65,,,fee schedule,,,,,,,,,,,,,,,975.65,,,fee schedule,,,,,,,,,985.37,,,fee schedule,,,,,,,,
NER-VEEG EA 12-26HR CONT MNTR,10368805,CDM,0740,RC,95716,CPT,210,EAPG,,,,outpatient,facility,,,2852.00,855.60,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHYS/QHP 2-12 HR W/O VID,10368806,CDM,0740,RC,95717,CPT,,,,,,outpatient,facility,,,643.00,192.90,273.27,726.0,,397.37,,,percent of total billed charges,,,,,,,,service not payable,313.78,,,percent of total billed charges,,,324.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,321.5,,,fee schedule,,,370.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,321.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,273.27,,,percent of total billed charges,,,,,,,,,482.25,,,percent of total billed charges,,,,,,,,service not payable,370.04,,,fee schedule,,,,,,,,,321.5,,,percent of total billed charges,,,,,,,,service not payable,482.25,,,percent of total billed charges,,,370.04,,,fee schedule,,,289.35,,,fee schedule,,,,,,,,,546.55,,,percent of total billed charges,,,295.78,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,321.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHYS/QHP 2-12 HR W/O VID,10368806,CDM,0740,RC,95717,CPT,211,EAPG,,,,outpatient,facility,,,643.00,192.90,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHYS/QHP 2-12 HR W/VEEG,10368807,CDM,0740,RC,95718,CPT,,,,,,outpatient,facility,,,839.00,251.70,356.57,726.0,,518.5,,,percent of total billed charges,,,,,,,,service not payable,409.43,,,percent of total billed charges,,,423.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,419.5,,,fee schedule,,,370.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,419.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,356.57,,,percent of total billed charges,,,,,,,,,629.25,,,percent of total billed charges,,,,,,,,service not payable,370.04,,,fee schedule,,,,,,,,,419.5,,,percent of total billed charges,,,,,,,,service not payable,629.25,,,percent of total billed charges,,,370.04,,,fee schedule,,,377.55,,,fee schedule,,,,,,,,,713.15,,,percent of total billed charges,,,385.94,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,419.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHYS/QHP 2-12 HR W/VEEG,10368807,CDM,0740,RC,95718,CPT,211,EAPG,,,,outpatient,facility,,,839.00,251.70,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHYS/QHP EA INCR W/O VID,10368808,CDM,0740,RC,95719,CPT,,,,,,outpatient,facility,,,991.00,297.30,421.18,842.35,,612.44,,,percent of total billed charges,,,,,,,,service not payable,483.61,,,percent of total billed charges,,,499.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,495.5,,,fee schedule,,,740.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,495.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,421.18,,,percent of total billed charges,,,,,,,,,743.25,,,percent of total billed charges,,,,,,,,service not payable,740.08,,,fee schedule,,,,,,,,,495.5,,,percent of total billed charges,,,,,,,,service not payable,743.25,,,percent of total billed charges,,,740.08,,,fee schedule,,,445.95,,,fee schedule,,,,,,,,,842.35,,,percent of total billed charges,,,455.86,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,495.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHYS/QHP EA INCR W/O VID,10368808,CDM,0740,RC,95719,CPT,211,EAPG,,,,outpatient,facility,,,991.00,297.30,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP EA INCR W/VEEG,10368809,CDM,0740,RC,95720,CPT,,,,,,outpatient,facility,,,1298.00,389.40,551.65,1103.3,,802.16,,,percent of total billed charges,,,,,,,,service not payable,633.42,,,percent of total billed charges,,,654.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,649.0,,,fee schedule,,,740.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,649.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,551.65,,,percent of total billed charges,,,,,,,,,973.5,,,percent of total billed charges,,,,,,,,service not payable,740.08,,,fee schedule,,,,,,,,,649.0,,,percent of total billed charges,,,,,,,,service not payable,973.5,,,percent of total billed charges,,,740.08,,,fee schedule,,,584.10,,,fee schedule,,,,,,,,,1103.3,,,percent of total billed charges,,,597.08,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,649.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP EA INCR W/VEEG,10368809,CDM,0740,RC,95720,CPT,211,EAPG,,,,outpatient,facility,,,1298.00,389.40,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP>36<60 HR W/O VID,10368810,CDM,0740,RC,95721,CPT,,,,,,outpatient,facility,,,1302.00,390.60,553.35,1819.36,,804.64,,,percent of total billed charges,,,,,,,,service not payable,635.38,,,percent of total billed charges,,,656.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,651.0,,,fee schedule,,,1302.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,651.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,553.35,,,percent of total billed charges,,,,,,,,,976.5,,,percent of total billed charges,,,,,,,,service not payable,1819.36,,,fee schedule,,,,,,,,,651.0,,,percent of total billed charges,,,,,,,,service not payable,976.5,,,percent of total billed charges,,,1302.0,,,fee schedule,,,585.90,,,fee schedule,,,,,,,,,1106.7,,,percent of total billed charges,,,598.92,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,651.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP>36<60 HR W/O VID,10368810,CDM,0740,RC,95721,CPT,211,EAPG,,,,outpatient,facility,,,1302.00,390.60,470.58,903.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,903.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,768.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,482.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,470.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,517.64,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP>36<60 HR W/VEEG,10368811,CDM,0740,RC,95722,CPT,,,,,,outpatient,facility,,,1583.00,474.90,639.0,1819.36,,978.29,,,percent of total billed charges,,,,,,,,service not payable,772.5,,,percent of total billed charges,,,798.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,791.5,,,fee schedule,,,1583.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,791.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,672.77,,,percent of total billed charges,,,,,,,,,1187.25,,,percent of total billed charges,,,,,,,,service not payable,1819.36,,,fee schedule,,,,,,,,,791.5,,,percent of total billed charges,,,,,,,,service not payable,1187.25,,,percent of total billed charges,,,1583.0,,,fee schedule,,,712.35,,,fee schedule,,,,,,,,,1345.55,,,percent of total billed charges,,,728.18,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,791.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP>36<60 HR W/VEEG,10368811,CDM,0740,RC,95722,CPT,210,EAPG,,,,outpatient,facility,,,1583.00,474.90,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP>60<84 HR W/O VID,10368812,CDM,0740,RC,95723,CPT,,,,,,outpatient,facility,,,1607.00,482.10,639.0,2559.44,,993.13,,,percent of total billed charges,,,,,,,,service not payable,784.22,,,percent of total billed charges,,,810.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,803.5,,,fee schedule,,,1607.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,803.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,682.98,,,percent of total billed charges,,,,,,,,,1205.25,,,percent of total billed charges,,,,,,,,service not payable,2559.44,,,fee schedule,,,,,,,,,803.5,,,percent of total billed charges,,,,,,,,service not payable,1205.25,,,percent of total billed charges,,,1607.0,,,fee schedule,,,723.15,,,fee schedule,,,,,,,,,1365.95,,,percent of total billed charges,,,739.22,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,803.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP>60<84 HR W/O VID,10368812,CDM,0740,RC,95723,CPT,210,EAPG,,,,outpatient,facility,,,1607.00,482.10,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP>60<84 HR W/VEEG,10368813,CDM,0740,RC,95724,CPT,,,,,,outpatient,facility,,,2018.00,605.40,639.0,2559.44,,1247.12,,,percent of total billed charges,,,,,,,,service not payable,984.78,,,percent of total billed charges,,,1017.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1009.0,,,fee schedule,,,2018.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,1009.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,857.65,,,percent of total billed charges,,,,,,,,,1513.5,,,percent of total billed charges,,,,,,,,service not payable,2559.44,,,fee schedule,,,,,,,,,1009.0,,,percent of total billed charges,,,,,,,,service not payable,1513.5,,,percent of total billed charges,,,2018.0,,,fee schedule,,,908.10,,,fee schedule,,,,,,,,,1715.3,,,percent of total billed charges,,,928.28,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,1009.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP>60<84 HR W/VEEG,10368813,CDM,0740,RC,95724,CPT,210,EAPG,,,,outpatient,facility,,,2018.00,605.40,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP>84 HR W/O VID,10368814,CDM,0740,RC,95725,CPT,,,,,,outpatient,facility,,,1830.00,549.00,639.0,2590.28,,1130.94,,,percent of total billed charges,,,,,,,,service not payable,893.04,,,percent of total billed charges,,,923.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,915.0,,,fee schedule,,,1830.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,915.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,777.75,,,percent of total billed charges,,,,,,,,,1372.5,,,percent of total billed charges,,,,,,,,service not payable,2590.28,,,fee schedule,,,,,,,,,915.0,,,percent of total billed charges,,,,,,,,service not payable,1372.5,,,percent of total billed charges,,,1830.0,,,fee schedule,,,823.5,,,fee schedule,,,,,,,,,1555.5,,,percent of total billed charges,,,841.80,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,915.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP>84 HR W/O VID,10368814,CDM,0740,RC,95725,CPT,210,EAPG,,,,outpatient,facility,,,1830.00,549.00,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NER-EEG PHY/QHP>84 HR W/VEEG,10368815,CDM,0740,RC,95726,CPT,,,,,,outpatient,facility,,,2550.00,765.00,639.0,2590.28,,1575.90,,,percent of total billed charges,,,,,,,,service not payable,1244.40,,,percent of total billed charges,,,1286.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1275.0,,,fee schedule,,,2550.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,1275.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1083.75,,,percent of total billed charges,,,,,,,,,1912.5,,,percent of total billed charges,,,,,,,,service not payable,2590.28,,,fee schedule,,,,,,,,,1275.0,,,percent of total billed charges,,,,,,,,service not payable,1912.5,,,percent of total billed charges,,,2550.0,,,fee schedule,,,1147.5,,,fee schedule,,,,,,,,,2167.5,,,percent of total billed charges,,,1173.0,,,percent of total billed charges,,,,,,,,,726.0,,,per diem,,,,,,,,service not payable,,,,,,,639.0,,,per diem,,,1275.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
NER-EEG PHY/QHP>84 HR W/VEEG,10368815,CDM,0740,RC,95726,CPT,210,EAPG,,,,outpatient,facility,,,2550.00,765.00,652.01,1146.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1146.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,974.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,652.01,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,923.43,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ATUN TIB AUG LM/RL SZ 7/8 10MM,10369046,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATUN TIB AUG LM/RL SZ 7/8 10MM,10369046,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART BCS STD 1-2 9MM LT,10369048,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS STD 1-2 9MM LT,10369048,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB LT 3,10369049,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB LT 3,10369049,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP 2H 2.4-2.7X35MM,10369050,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP 2H 2.4-2.7X35MM,10369050,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FT LCP VS 2.4-2.7X43MM,10369051,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6403.00,1920.90,2484.36,5442.55,,3137.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2689.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2484.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2721.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4802.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3201.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5442.55,,,percent of total billed charges,,,2881.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FT LCP VS 2.4-2.7X43MM,10369051,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6403.00,1920.90,2689.26,5442.55,,3137.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2689.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3229.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2721.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4802.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3201.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4802.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5442.55,,,percent of total billed charges,,,2945.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM LPS COB CEM 14X125MM,10369052,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15835.00,4750.50,6143.98,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6143.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13459.75,,,percent of total billed charges,,,7125.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM LPS COB CEM 14X125MM,10369052,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15835.00,4750.50,6650.70,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7987.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13459.75,,,percent of total billed charges,,,7284.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS FEMORAL LT SZ 5 CEM,10369053,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEMORAL LT SZ 5 CEM,10369053,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL CS X3 SZ5 13MM,10369054,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL CS X3 SZ5 13MM,10369054,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 560CC,10369075,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 560CC,10369075,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC EDGE LOTUS 23MM,10369076,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC EDGE LOTUS 23MM,10369076,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC EDGE LOTUS 25MM,10369077,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC EDGE LOTUS 25MM,10369077,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC EDGE LOTUS 27MM,10369078,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC EDGE LOTUS 27MM,10369078,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LCKNG T15 3.5MM 40MM,10369082,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1662.00,498.60,644.86,1412.7,,,,,,,,,,,,,,,,,,,,644.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1246.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,831.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1412.7,,,percent of total billed charges,,,747.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LCKNG T15 3.5MM 40MM,10369082,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1662.00,498.60,706.35,1412.7,,,,,,,,,,,,,service not payable,,,,,,,838.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,706.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1246.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,831.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1246.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,764.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LCKNG T15 3.5MM 54MM,10369083,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1662.00,498.60,644.86,1412.7,,,,,,,,,,,,,,,,,,,,644.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1246.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,831.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1412.7,,,percent of total billed charges,,,747.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LCKNG T15 3.5MM 54MM,10369083,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1662.00,498.60,706.35,1412.7,,,,,,,,,,,,,service not payable,,,,,,,838.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,706.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1246.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,831.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1246.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,764.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LCKNG T15 3.5MM 56MM,10369084,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1662.00,498.60,644.86,1412.7,,,,,,,,,,,,,,,,,,,,644.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1246.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,831.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1412.7,,,percent of total billed charges,,,747.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LCKNG T15 3.5MM 56MM,10369084,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1662.00,498.60,706.35,1412.7,,,,,,,,,,,,,service not payable,,,,,,,838.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,706.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1246.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,831.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1246.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,764.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP BND VA 3.5X147MM,10369085,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12379.00,3713.70,4803.05,10522.15,,6065.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5199.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4803.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5261.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9284.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6189.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10522.15,,,percent of total billed charges,,,5570.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP BND VA 3.5X147MM,10369085,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12379.00,3713.70,5199.18,10522.15,,6065.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5199.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6243.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5261.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9284.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6189.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9284.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10522.15,,,percent of total billed charges,,,5694.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK ST VAR ANG 2.7X24MM,10369086,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1497.00,449.10,580.84,1272.45,,,,,,,,,,,,,,,,,,,,580.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,636.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1122.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1272.45,,,percent of total billed charges,,,673.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK ST VAR ANG 2.7X24MM,10369086,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1497.00,449.10,636.23,1272.45,,,,,,,,,,,,,service not payable,,,,,,,755.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,636.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1122.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1122.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1272.45,,,percent of total billed charges,,,688.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PERICARDIOCENTESIS W/IMAGING,10369218,CDM,0450,RC,33016,CPT,,,,,,outpatient,facility,,,5117.00,1535.10,774.0,4349.45,,3162.31,,,percent of total billed charges,,,,,,,,,2497.10,,,percent of total billed charges,,,2581.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3837.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3837.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4349.45,,,percent of total billed charges,,,2353.82,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
PERICARDIOCENTESIS W/IMAGING,10369218,CDM,0450,RC,33016,CPT,05182,APC,,,,outpatient,facility,,,5117.00,1535.10,714.45,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,714.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,714.45,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,714.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
PERICARDIOCENTESIS W/IMAGING,10369218,CDM,0450,RC,33016,CPT,68,EAPG,,,,outpatient,facility,,,5117.00,1535.10,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PRCRD DRG 6YR W/O CGEN CAR,10369219,CDM,0450,RC,33017,CPT,,,,,,outpatient,facility,,,5117.00,1535.10,220.26,10719.0,,5117.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,10719.0,,,case rate,,,2581.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,220.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,3837.75,,,percent of total billed charges,,,,,,,,service not payable,220.26,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,service not payable,3837.75,,,percent of total billed charges,,,1176.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,4349.45,,,percent of total billed charges,,,2353.82,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PRCRD DRG 6YR W/O CGEN CAR,10369219,CDM,0450,RC,33017,CPT,68,EAPG,,,,outpatient,facility,,,5117.00,1535.10,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PRCRD DRG 0-5YR OR W/ANOMLY,10369220,CDM,0450,RC,33018,CPT,,,,,,outpatient,facility,,,5117.00,1535.10,220.26,10719.0,,5117.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,10719.0,,,case rate,,,2581.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,220.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,3837.75,,,percent of total billed charges,,,,,,,,service not payable,220.26,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,service not payable,3837.75,,,percent of total billed charges,,,1176.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,4349.45,,,percent of total billed charges,,,2353.82,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PRCRD DRG 0-5YR OR W/ANOMLY,10369220,CDM,0450,RC,33018,CPT,68,EAPG,,,,outpatient,facility,,,5117.00,1535.10,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PERQ PRCRD DRG INSJ CATH CT,10369221,CDM,0450,RC,33019,CPT,,,,,,outpatient,facility,,,5117.00,1535.10,220.26,10719.0,,5117.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,10719.0,,,case rate,,,2581.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,220.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,3837.75,,,percent of total billed charges,,,,,,,,service not payable,220.26,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,service not payable,3837.75,,,percent of total billed charges,,,1176.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",,,,,,service not payable,,,,,,,4349.45,,,percent of total billed charges,,,2353.82,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,service not payable,,,,,,,774.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PERQ PRCRD DRG INSJ CATH CT,10369221,CDM,0450,RC,33019,CPT,68,EAPG,,,,outpatient,facility,,,5117.00,1535.10,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Phrenic Nerve Injection,10369222,CDM,0450,RC,64999,CPT,,,,,,outpatient,facility,,,1410.00,423.00,648.60,1198.5,,871.38,,,percent of total billed charges,,,,,,,,,688.08,,,percent of total billed charges,,,711.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1198.5,,,percent of total billed charges,,,648.60,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Phrenic Nerve Injection,10369222,CDM,0450,RC,64999,CPT,05441,APC,,,,outpatient,facility,,,1410.00,423.00,135.76,650.16,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,595.5,,,fee schedule,,,135.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",288.74,,,fee schedule,,,650.16,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,586.87,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,135.76,,,fee schedule,,,288.74,,,fee schedule,,,,,,,,,283.08,,,fee schedule,,,,,,,,,135.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",288.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,,,,,,,283.08,,,fee schedule,,,,,,,,,285.90,,,fee schedule,,,,,,,,
Phrenic Nerve Injection,10369222,CDM,0450,RC,64999,CPT,214,EAPG,,,,outpatient,facility,,,1410.00,423.00,561.72,1059.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,900.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,580.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,561.72,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,617.89,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WIRE NITREX BLUE .035 X 145,10369331,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,809.00,242.70,343.82,687.65,,499.96,,,percent of total billed charges,,,,,,,,service not payable,394.79,,,percent of total billed charges,,,408.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,343.82,,,percent of total billed charges,,,,,,,,,606.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,404.5,,,percent of total billed charges,,,,,,,,service not payable,606.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,687.65,,,percent of total billed charges,,,372.14,,,percent of total billed charges,,,,,,,,,525.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,525.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 375CC,10369332,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 375CC,10369332,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75D 28.5,10369333,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75D 28.5,10369333,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 20.0D 1.5,10369334,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 20.0D 1.5,10369334,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 2X40MM,10369335,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 3X40MM,10369336,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 4X40MM,10369337,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 5X40MM,10369338,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 6X40MM,10369339,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 3X100MM,10369340,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 4X100MM,10369341,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 5X100MM,10369342,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 6X100MM,10369343,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 2X150MM,10369344,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 3X150MM,10369345,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 4X150MM,10369346,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 5X150MM,10369347,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 6X150MM,10369348,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 2X200MM,10369349,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 3X200MM,10369350,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 4X200MM,10369351,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 5X200MM,10369352,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON R2P 200CM 6X200MM,10369353,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1974.00,592.20,838.95,1677.90,,1219.93,,,percent of total billed charges,,,,,,,,service not payable,963.31,,,percent of total billed charges,,,995.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,838.95,,,percent of total billed charges,,,,,,,,,1480.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,987.0,,,percent of total billed charges,,,,,,,,service not payable,1480.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1677.90,,,percent of total billed charges,,,908.04,,,percent of total billed charges,,,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1283.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 6X40MM,10369354,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 6X40MM,10369354,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 6X60MM,10369355,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 6X60MM,10369355,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 6X80MM,10369356,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 6X80MM,10369356,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 6X100MM,10369357,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 6X100MM,10369357,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 6X120MM,10369358,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 6X120MM,10369358,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 6X150MM,10369359,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 6X150MM,10369359,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 7X40MM,10369360,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 7X40MM,10369360,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 7X80MM,10369361,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 7X80MM,10369361,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 7X100MM,10369362,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 7X100MM,10369362,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 7X120MM,10369363,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 7X120MM,10369363,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 7X150MM,10369364,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 7X150MM,10369364,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 8X40MM,10369365,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 8X40MM,10369365,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 8X60MM,10369366,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 8X60MM,10369366,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 8X80MM,10369367,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 8X80MM,10369367,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT S-EXP 200CM 6F 8X100MM,10369368,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT S-EXP 200CM 6F 8X100MM,10369368,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MYOCRD STRAIN IMG SPCKL TRCK,10369676,CDM,0480,RC,93356,CPT,,,,,,outpatient,facility,,,2527.00,758.10,1073.97,2147.95,,1561.69,,,percent of total billed charges,,,,,,,,service not payable,1233.18,,,percent of total billed charges,,,1274.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1073.97,,,percent of total billed charges,,,,,,,,,1895.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1263.5,,,percent of total billed charges,,,,,,,,service not payable,1895.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2147.95,,,percent of total billed charges,,,1162.42,,,percent of total billed charges,,,,,,,,,2075.0,,,per diem,,,,,,,,service not payable,,,,,,,1826.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MYOCRD STRAIN IMG SPCKL TRCK,10369676,CDM,0480,RC,93356,CPT,81,EAPG,,,,outpatient,facility,,,2527.00,758.10,630.02,1789.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1789.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1520.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1051.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1156.67,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW PT ST LK CONI 3.5X70MM,10369847,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1651.00,495.30,640.59,1403.35,,,,,,,,,,,,,,,,,,,,640.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,701.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1238.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,825.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1403.35,,,percent of total billed charges,,,742.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PT ST LK CONI 3.5X70MM,10369847,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1651.00,495.30,701.67,1403.35,,,,,,,,,,,,,service not payable,,,,,,,832.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,701.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1238.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,825.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1238.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1403.35,,,percent of total billed charges,,,759.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 5 14MM,10370223,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 5 14MM,10370223,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA TRI ASYM X3 A29 9MM,10370225,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA TRI ASYM X3 A29 9MM,10370225,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA TRI ASYM X3 A35 10MM,10370227,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA TRI ASYM X3 A35 10MM,10370227,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 6 10MM,10370229,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 6 10MM,10370229,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMAX W/INST 18WX18L,10370231,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8180.00,2454.00,3173.84,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3173.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6953.0,,,percent of total billed charges,,,3681.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMAX W/INST 18WX18L,10370231,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8180.00,2454.00,3435.60,6953.0,,4008.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3435.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4125.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3476.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6135.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4090.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6135.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6953.0,,,percent of total billed charges,,,3762.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER VASC 6F 13CM,10370232,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,232.00,69.60,98.60,197.20,,143.38,,,percent of total billed charges,,,,,,,,service not payable,113.22,,,percent of total billed charges,,,117.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,98.60,,,percent of total billed charges,,,,,,,,,174.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,116.0,,,percent of total billed charges,,,,,,,,service not payable,174.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,197.20,,,percent of total billed charges,,,106.72,,,percent of total billed charges,,,,,,,,,150.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,150.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS ACRYLIC 20.5 D 6MM,10370233,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3951.00,1185.30,1532.99,3358.35,,,,,,,,,,,,,,,,,,,,1532.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.35,,,percent of total billed charges,,,1777.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS ACRYLIC 20.5 D 6MM,10370233,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3951.00,1185.30,1679.18,3358.35,,,,,,,,,,,,,service not payable,,,,,,,1992.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1975.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1679.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2963.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1975.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2963.25,,,percent of total billed charges,,,,,,,,service not payable,1777.95,,,fee schedule,,,,,,,,,3358.35,,,percent of total billed charges,,,1817.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1975.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7.0X50MM X_71129050 X_SMITH NEPHEW,10370234,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7.0X50MM X_71129050 X_SMITH NEPHEW,10370234,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 7.0X45MM X_71129045 X_SMITH NEPHEW,10370235,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7.0X45MM X_71129045 X_SMITH NEPHEW,10370235,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL TR CR X3 3 11MM,10370238,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL TR CR X3 3 11MM,10370238,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DIAPHRAGM ARCING LF 85MM,10370239,CDM,0272,RC,A4266,HCPCS,,,,,,outpatient,facility,,,286.00,85.80,121.55,243.10,,176.75,,,percent of total billed charges,,,,,,,,service not payable,139.57,,,percent of total billed charges,,,144.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,143.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,143.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,121.55,,,percent of total billed charges,,,,,,,,,214.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,143.0,,,percent of total billed charges,,,,,,,,service not payable,214.5,,,percent of total billed charges,,,,,,,,service not payable,128.70,,,fee schedule,,,,,,,,,243.10,,,percent of total billed charges,,,131.56,,,percent of total billed charges,,,,,,,,,185.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,185.90,,,percent of total billed charges,,,143.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB TRI CS X3 SZ4 11MM,10370240,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB TRI CS X3 SZ4 11MM,10370240,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 4.5D 20.0,10370241,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 4.5D 20.0,10370241,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON TRACTION FIX DOG BONE,10370244,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUTTON TRACTION FIX DOG BONE,10370244,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 2X10MM,10370245,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,4131.00,1239.30,1602.83,3511.35,,,,,,,,,,,,,,,,,,,,1602.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3511.35,,,percent of total billed charges,,,1858.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 2X10MM,10370245,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,4131.00,1239.30,1755.68,3511.35,,,,,,,,,,,,,service not payable,,,,,,,2083.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3511.35,,,percent of total billed charges,,,1900.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 2X10MM,10370245,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,4131.00,1239.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 3X10MM,10370246,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,4131.00,1239.30,1602.83,3511.35,,,,,,,,,,,,,,,,,,,,1602.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3511.35,,,percent of total billed charges,,,1858.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 3X10MM,10370246,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,4131.00,1239.30,1755.68,3511.35,,,,,,,,,,,,,service not payable,,,,,,,2083.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3511.35,,,percent of total billed charges,,,1900.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 3X10MM,10370246,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,4131.00,1239.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 6X10MM,10370247,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,4131.00,1239.30,1602.83,3511.35,,,,,,,,,,,,,,,,,,,,1602.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3511.35,,,percent of total billed charges,,,1858.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 6X10MM,10370247,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,4131.00,1239.30,1755.68,3511.35,,,,,,,,,,,,,service not payable,,,,,,,2083.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3511.35,,,percent of total billed charges,,,1900.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 6X10MM,10370247,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,4131.00,1239.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 6X15MM,10370248,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,4131.00,1239.30,1602.83,3511.35,,,,,,,,,,,,,,,,,,,,1602.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3511.35,,,percent of total billed charges,,,1858.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 6X15MM,10370248,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,4131.00,1239.30,1755.68,3511.35,,,,,,,,,,,,,service not payable,,,,,,,2083.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3511.35,,,percent of total billed charges,,,1900.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 6X15MM,10370248,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,4131.00,1239.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 7X15MM,10370249,CDM,0278,RC,C9364,HCPCS,,,,,,inpatient,facility,,,4131.00,1239.30,1602.83,3511.35,,,,,,,,,,,,,,,,,,,,1602.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3511.35,,,percent of total billed charges,,,1858.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NERVE 7X15MM,10370249,CDM,0278,RC,C9364,HCPCS,,,,,,outpatient,facility,,,4131.00,1239.30,1755.68,3511.35,,,,,,,,,,,,,service not payable,,,,,,,2083.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1755.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3098.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2065.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3511.35,,,percent of total billed charges,,,1900.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NERVE 7X15MM,10370249,CDM,0278,RC,C9364,HCPCS,455,EAPG,,,,outpatient,facility,,,4131.00,1239.30,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH SET SALIVARY DUCT BAL,10370250,CDM,0272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,1336.73,,,percent of total billed charges,,,,,,,,service not payable,1055.54,,,percent of total billed charges,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,1405.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1405.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB BCS SZ3-4 11MM LT,10370252,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB BCS SZ3-4 11MM LT,10370252,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II LT SZ5,10370253,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II LT SZ5,10370253,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ABLATION BI-D DF CURVE,10370531,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,10162.00,3048.60,4318.85,8637.70,,6280.12,,,percent of total billed charges,,,,,,,,service not payable,4959.06,,,percent of total billed charges,,,5125.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4318.85,,,percent of total billed charges,,,,,,,,,7621.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5081.0,,,percent of total billed charges,,,,,,,,service not payable,7621.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8637.70,,,percent of total billed charges,,,4674.52,,,percent of total billed charges,,,,,,,,,6605.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6605.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT INT BRACE 2X2 4.75 CC FT,10370533,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT INT BRACE 2X2 4.75 CC FT,10370533,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 265CC,10370534,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 265CC,10370534,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 280CC,10370535,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 280CC,10370535,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FIBULOCK 3.8X130MM LEFT,10370538,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FIBULOCK 3.8X130MM LEFT,10370538,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS CTX 3.5X26MM,10370539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS CTX 3.5X26MM,10370539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS CTX 3.5X34MM,10370540,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS CTX 3.5X34MM,10370540,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS CTX 3.5X44MM,10370541,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS CTX 3.5X44MM,10370541,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW EVOS KCJ 3.5X32MM,10370542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6980.00,2094.00,2708.24,5933.0,,3420.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2931.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2708.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2966.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5235.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3490.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5933.0,,,percent of total billed charges,,,3141.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW EVOS KCJ 3.5X32MM,10370542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6980.00,2094.00,2931.60,5933.0,,3420.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2931.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3520.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2966.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5235.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3490.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5235.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5933.0,,,percent of total billed charges,,,3210.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE EVOS 3.5X63MM PD TIBIA 3,10370544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3076.00,922.80,1193.49,2614.60,,,,,,,,,,,,,,,,,,,,1193.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1307.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2307.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1538.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2614.60,,,percent of total billed charges,,,1384.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE EVOS 3.5X63MM PD TIBIA 3,10370544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3076.00,922.80,1307.3,2614.60,,,,,,,,,,,,,service not payable,,,,,,,1551.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1307.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2307.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1538.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2307.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2614.60,,,percent of total billed charges,,,1414.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NM Exam,10370764,CDM,0340,RC,78800,CPT,,,,,,outpatient,facility,,,2685.00,805.50,347.26,2282.25,,465.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,347.26,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370764,CDM,0340,RC,78800,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370764,CDM,0340,RC,78800,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370766,CDM,0340,RC,78800,CPT,,,,,,outpatient,facility,,,2685.00,805.50,347.26,2282.25,,465.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,347.26,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370766,CDM,0340,RC,78800,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370766,CDM,0340,RC,78800,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370768,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370768,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370768,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370770,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370770,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370770,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370772,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370772,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370772,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370774,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370774,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370774,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370776,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370776,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
NM Exam,10370776,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370778,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370778,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370778,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370780,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370780,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370780,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370782,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370782,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370782,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370818,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370818,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370818,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370820,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370820,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370820,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370822,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370822,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370822,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370824,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370824,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370824,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370826,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370826,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370826,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370828,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370828,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370828,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370830,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370830,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370830,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370832,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370832,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370832,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370834,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370834,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370834,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370836,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370836,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370836,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370838,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370838,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370838,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370840,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370840,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370840,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370842,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370842,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370842,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370844,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370844,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370844,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370846,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370846,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370846,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370848,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370848,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370848,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370850,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370850,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370850,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370852,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370852,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370852,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370854,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370854,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370854,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370856,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370856,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370856,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370858,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370858,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370858,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370860,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370860,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10370860,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370862,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370862,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
NM Exam,10370862,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370864,CDM,0341,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370864,CDM,0341,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
NM Exam,10370864,CDM,0341,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370866,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370866,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
NM Exam,10370866,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10370868,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10370868,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
NM Exam,10370868,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT ALT BCS STD 3-4 10MM LT,10370896,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ALT BCS STD 3-4 10MM LT,10370896,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 180MM,10370897,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,43699.00,13109.70,16955.21,37144.15,,21412.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18353.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16955.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18572.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32774.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21849.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37144.15,,,percent of total billed charges,,,19664.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 180MM,10370897,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,43699.00,13109.70,18353.58,37144.15,,21412.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18353.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,22041.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18572.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32774.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21849.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32774.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,37144.15,,,percent of total billed charges,,,20101.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK COMP NARROW 10H,10370898,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7440.00,2232.00,2886.72,6324.0,,3645.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3124.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2886.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3162.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5580.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3720.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6324.0,,,percent of total billed charges,,,3348.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK COMP NARROW 10H,10370898,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7440.00,2232.00,3124.80,6324.0,,3645.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3124.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3752.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3162.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5580.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3720.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5580.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6324.0,,,percent of total billed charges,,,3422.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CROSSLINK 6.35MM,10370899,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,274.00,82.20,106.31,232.90,,,,,,,,,,,,,,,,,,,,106.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,123.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CROSSLINK 6.35MM,10370899,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,,,,,,,,,,,,service not payable,,,,,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SPY PHI S PAQ,10370900,CDM,0290,RC,A9999,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,50.0,2229.55,,1621.01,,,percent of total billed charges,,,,,,,,service not payable,1280.02,,,percent of total billed charges,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1311.5,,,fee schedule,,,50.0,,Sum:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Table Per Unit   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N Plus:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Table Per Unit    [[IOWA MCD ADD B MF MAX UNIT RATE PROCS]] 100.00% of Table   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N End Sum  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Sum:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Table Per Unit   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N Plus:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Table Per Unit    [[IOWA MCD ADD B MF MAX UNIT RATE PROCS]] 100.00% of Table   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N End Sum  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,1311.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1114.78,,,percent of total billed charges,,,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,50.0,,Sum:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Table Per Unit   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N Plus:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Table Per Unit    [[IOWA MCD ADD B MF MAX UNIT RATE PROCS]] 100.00% of Table   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N End Sum ,other,,Sum:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF NO MAX UNIT PROCS]] 100.00% of Table Per Unit   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N Plus:  Procedure Lookup:   Procedure Code Tables:    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Charges    [[IOWA MCD ADD B MF MAX UNIT PROCS]] 100.00% of Table Per Unit    [[IOWA MCD ADD B MF MAX UNIT RATE PROCS]] 100.00% of Table   Multipliers: 100.00%   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: Lowest Reimbursement    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: None    LSS reimbursement: N End Sum ,,,,,,,1311.5,,,percent of total billed charges,,,,,,,,service not payable,1967.25,,,percent of total billed charges,,,50.0,,,percent of total billed charges,,,1180.35,,,fee schedule,,,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE GORILLA LAP 2MM,10370902,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4819.00,1445.70,1869.77,4096.15,,,,,,,,,,,,,,,,,,,,1869.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2048.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3614.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2409.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4096.15,,,percent of total billed charges,,,2168.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE GORILLA LAP 2MM,10370902,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4819.00,1445.70,2048.07,4096.15,,,,,,,,,,,,,service not payable,,,,,,,2430.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2048.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3614.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2409.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3614.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4096.15,,,percent of total billed charges,,,2216.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING PLATE 3.5X16MM,10370903,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING PLATE 3.5X16MM,10370903,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING PLATE 3.5X20MM,10370904,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING PLATE 3.5X20MM,10370904,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HDLS ST MM 3.5X36MM,10370906,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1360.00,408.00,527.68,1156.0,,,,,,,,,,,,,,,,,,,,527.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,,612.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HDLS ST MM 3.5X36MM,10370906,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1360.00,408.00,578.0,1156.0,,,,,,,,,,,,,service not payable,,,,,,,685.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,,625.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER VASC 8 FR X 0.038IN,10370907,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,337.43,,,percent of total billed charges,,,,,,,,service not payable,266.45,,,percent of total billed charges,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MJFL Exam,10371004,CDM,0761,RC,62329,CPT,,,,,,outpatient,facility,,,3254.00,976.20,118.0,2765.90,,2010.97,,,percent of total billed charges,,,,,,,,,1587.95,,,percent of total billed charges,,,1641.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1382.95,,,percent of total billed charges,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1627.0,,,percent of total billed charges,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2765.90,,,percent of total billed charges,,,1496.84,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MJFL Exam,10371004,CDM,0761,RC,62329,CPT,05442,APC,,,,outpatient,facility,,,3254.00,976.20,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
MJFL Exam,10371004,CDM,0761,RC,62329,CPT,53,EAPG,,,,outpatient,facility,,,3254.00,976.20,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MECT Exam,10371006,CDM,0761,RC,62329,CPT,,,,,,outpatient,facility,,,3254.00,976.20,118.0,2765.90,,2010.97,,,percent of total billed charges,,,,,,,,,1587.95,,,percent of total billed charges,,,1641.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1382.95,,,percent of total billed charges,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1627.0,,,percent of total billed charges,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2765.90,,,percent of total billed charges,,,1496.84,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MECT Exam,10371006,CDM,0761,RC,62329,CPT,05442,APC,,,,outpatient,facility,,,3254.00,976.20,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
MECT Exam,10371006,CDM,0761,RC,62329,CPT,53,EAPG,,,,outpatient,facility,,,3254.00,976.20,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MECT Exam,10371008,CDM,0761,RC,62328,CPT,,,,,,outpatient,facility,,,3254.00,976.20,118.0,2765.90,,2010.97,,,percent of total billed charges,,,,,,,,,1587.95,,,percent of total billed charges,,,1641.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1382.95,,,percent of total billed charges,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1627.0,,,percent of total billed charges,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2765.90,,,percent of total billed charges,,,1496.84,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MECT Exam,10371008,CDM,0761,RC,62328,CPT,05442,APC,,,,outpatient,facility,,,3254.00,976.20,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
MECT Exam,10371008,CDM,0761,RC,62328,CPT,53,EAPG,,,,outpatient,facility,,,3254.00,976.20,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MEFL Exam,10371010,CDM,0490,RC,62328,CPT,,,,,,outpatient,facility,,,3254.00,976.20,1496.84,3254.0,,3254.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1641.32,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2440.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2765.90,,,percent of total billed charges,,,1496.84,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MEFL Exam,10371010,CDM,0490,RC,62328,CPT,05442,APC,,,,outpatient,facility,,,3254.00,976.20,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
MEFL Exam,10371010,CDM,0490,RC,62328,CPT,53,EAPG,,,,outpatient,facility,,,3254.00,976.20,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MJFL Exam,10371012,CDM,0320,RC,74221,CPT,,,,,,outpatient,facility,,,949.00,284.70,385.13,806.65,,586.48,,,percent of total billed charges,,,,,,,,,466.91,,,fee schedule,,,478.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.32,,,percent of total billed charges,,,,,,,,,711.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,474.5,,,percent of total billed charges,,,,,,,,,711.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.65,,,percent of total billed charges,,,436.54,,,percent of total billed charges,,,,,,,,,385.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MJFL Exam,10371012,CDM,0320,RC,74221,CPT,05571,APC,,,,outpatient,facility,,,949.00,284.70,163.74,392.09,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,359.12,,,fee schedule,,,163.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",174.12,,,fee schedule,,,392.09,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,353.92,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,163.74,,,fee schedule,,,174.12,,,fee schedule,,,,,,,,,170.71,,,fee schedule,,,,,,,,,163.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",174.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.71,,,fee schedule,,,,,,,,,,,,,,,170.71,,,fee schedule,,,,,,,,,172.41,,,fee schedule,,,,,,,,
MJFL Exam,10371012,CDM,0320,RC,74221,CPT,389,EAPG,,,,outpatient,facility,,,949.00,284.70,172.18,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,287.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COUNTERSINK MATTA 4.5 6.5.0MM,10371292,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2202.00,660.60,854.38,1871.7,,,,,,,,,,,,,,,,,,,,854.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,990.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COUNTERSINK MATTA 4.5 6.5.0MM,10371292,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2202.00,660.60,935.85,1871.7,,,,,,,,,,,,,service not payable,,,,,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK 5.0X26MM,10371293,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK 5.0X26MM,10371293,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR FB SZ9 6MM,10371294,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR FB SZ9 6MM,10371294,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY HUMERAL MINI 40MM  10MM,10371883,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY HUMERAL MINI 40MM  10MM,10371883,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM MICRO 18 X 55MM,10371884,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM MICRO 18 X 55MM,10371884,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 8DEG 10 X 22 X 28M,10371885,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6104.00,1831.20,2368.35,5188.40,,2990.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2563.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5188.40,,,percent of total billed charges,,,2746.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 8DEG 10 X 22 X 28M,10371885,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6104.00,1831.20,2563.68,5188.40,,2990.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2563.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3078.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5188.40,,,percent of total billed charges,,,2807.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE SACRAL 1 LEVEL 27MM,10371886,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6747.00,2024.10,2617.84,5734.95,,3306.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2833.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2617.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2867.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5060.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3373.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5734.95,,,percent of total billed charges,,,3036.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE SACRAL 1 LEVEL 27MM,10371886,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6747.00,2024.10,2833.74,5734.95,,3306.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2833.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3403.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2867.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5060.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3373.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5060.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5734.95,,,percent of total billed charges,,,3103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE STD 5 X 25MM,10371887,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1339.00,401.70,519.53,1138.15,,,,,,,,,,,,,,,,,,,,519.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,,602.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE STD 5 X 25MM,10371887,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1339.00,401.70,569.07,1138.15,,,,,,,,,,,,,service not payable,,,,,,,675.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,,615.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA TRI ASYM X3 A32 10MM,10371890,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA TRI ASYM X3 A32 10MM,10371890,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ART BCS XPLE SZ 7-8 RT,10372194,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS XPLE SZ 7-8 RT,10372194,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB RT 7,10372195,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB RT 7,10372195,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB RD PS SZ5 16MM X_1516-50-516 X_DEPUY,10372196,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB RD PS SZ5 16MM X_1516-50-516 X_DEPUY,10372196,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT TIB LM/RL SZ 3/4 15MM,10372197,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT TIB LM/RL SZ 3/4 15MM,10372197,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD SPINAL CORD 90CM,10372198,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,20325.00,6097.50,7886.10,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7886.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17276.25,,,percent of total billed charges,,,9146.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD SPINAL CORD 90CM,10372198,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,20325.00,6097.50,8536.5,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10251.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17276.25,,,percent of total billed charges,,,9349.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ4 11MM,10372199,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ4 11MM,10372199,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ6 9MM,10372200,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ6 9MM,10372200,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK AVS 11X25X4X11 DEG,10372201,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6104.00,1831.20,2368.35,5188.40,,2990.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2563.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5188.40,,,percent of total billed charges,,,2746.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 11X25X4X11 DEG,10372201,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6104.00,1831.20,2563.68,5188.40,,2990.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2563.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3078.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5188.40,,,percent of total billed charges,,,2807.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUT ANCHOR CORKSCREW 14.7X5.5,10372202,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUT ANCHOR CORKSCREW 14.7X5.5,10372202,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM WISE CRT,10372204,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,54637.00,16391.10,21199.16,46441.45,,26772.13,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22947.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,21199.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23220.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,40977.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27318.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46441.45,,,percent of total billed charges,,,24586.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM WISE CRT,10372204,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,54637.00,16391.10,22947.54,46441.45,,26772.13,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22947.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,27558.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,23220.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,40977.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27318.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,40977.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,46441.45,,,percent of total billed charges,,,25133.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ELECTRODE WISE RECEIVER,10372205,CDM,0278,RC,C1816,HCPCS,,,,,,inpatient,facility,,,24587.00,7376.10,9539.76,20898.95,,12047.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10326.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9539.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10449.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18440.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12293.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20898.95,,,percent of total billed charges,,,11064.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE WISE RECEIVER,10372205,CDM,0278,RC,C1816,HCPCS,,,,,,outpatient,facility,,,24587.00,7376.10,10326.54,20898.95,,12047.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10326.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12401.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10449.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18440.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12293.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18440.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,20898.95,,,percent of total billed charges,,,11310.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER WISE DELIVERY,10372206,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2786.30,5572.60,,4051.61,,,percent of total billed charges,,,,,,,,service not payable,3199.33,,,percent of total billed charges,,,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,4261.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4261.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BATTERY WISE PULSE GENERATOR,10372207,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,,percent of total billed charges,,Paid in addition to inpatient services ,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BATTERY WISE PULSE GENERATOR,10372207,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,,percent of total billed charges,,Paid in addition to outpatient services ,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRANSMITER WISE PULSE GENERA,10372208,CDM,0278,RC,C1786,HCPCS,,,,,,inpatient,facility,,,22948.00,6884.40,8903.82,19505.80,,11244.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9638.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8903.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11474.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19505.80,,,percent of total billed charges,,,10326.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRANSMITER WISE PULSE GENERA,10372208,CDM,0278,RC,C1786,HCPCS,,,,,,outpatient,facility,,,22948.00,6884.40,9638.16,19505.80,,11244.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9638.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11574.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11474.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17211.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19505.80,,,percent of total billed charges,,,10556.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB LT 8,10372211,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB LT 8,10372211,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75D 20.5,10372212,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2163.00,648.90,839.24,1838.55,,,,,,,,,,,,,,,,,,,,839.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1838.55,,,percent of total billed charges,,,973.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75D 20.5,10372212,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2163.00,648.90,919.27,1838.55,,,,,,,,,,,,,service not payable,,,,,,,1091.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,919.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1622.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1081.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1622.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1838.55,,,percent of total billed charges,,,994.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET TRIT SOLIDBACK 62G,10372213,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET TRIT SOLIDBACK 62G,10372213,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0301,10372214,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0301,10372214,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0101,10372215,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0101,10372215,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0102,10372216,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0102,10372216,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0103,10372217,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0103,10372217,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0201,10372218,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0201,10372218,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0202,10372219,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0202,10372219,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0203,10372220,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0203,10372220,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0302,10372221,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0302,10372221,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MITRACLIP BUNDLE MBR0303,10372222,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITRACLIP BUNDLE MBR0303,10372222,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY SURESTEP BARDEX IC 14F,10372625,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,99.00,29.70,42.08,84.15,,61.18,,,percent of total billed charges,,,,,,,,service not payable,48.31,,,percent of total billed charges,,,49.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.08,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,74.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,64.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,64.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 3 LVL 54MM,10372817,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 3 LVL 54MM,10372817,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH WOLVERINE 3X15MM,10372818,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3324.00,997.20,1412.7,2825.40,,2054.23,,,percent of total billed charges,,,,,,,,service not payable,1622.11,,,percent of total billed charges,,,1676.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1412.7,,,percent of total billed charges,,,,,,,,,2493.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1662.0,,,percent of total billed charges,,,,,,,,service not payable,2493.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2825.40,,,percent of total billed charges,,,1529.04,,,percent of total billed charges,,,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2160.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP FIRSTICE ORTHO KNEE,10373112,CDM,0274,RC,L1846,HCPCS,,,,,,inpatient,facility,,,504.00,151.20,195.55,428.40,,,,,,,,,,,,,,,,,,,,195.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,378.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,252.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.40,,,percent of total billed charges,,,226.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WRAP FIRSTICE ORTHO KNEE,10373112,CDM,0274,RC,L1846,HCPCS,,,,,,outpatient,facility,,,504.00,151.20,214.20,1139.04,,,,,,,,495.94,,,fee schedule,,,,,,,,,254.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1043.28,,,fee schedule,,,504.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",505.86,,,fee schedule,,,1139.04,,,fee schedule,,,,,,,,,495.94,,,fee schedule,,,,,,,,,214.20,,,percent of total billed charges,,Paid in addition to outpatient services ,1028.16,,,fee schedule,,,378.0,,,percent of total billed charges,,,495.94,,,fee schedule,,,504.0,,,fee schedule,,,505.86,,,fee schedule,,,252.0,,,percent of total billed charges,,Paid in addition to outpatient services ,495.94,,,fee schedule,,,378.0,,,percent of total billed charges,,,504.0,,,fee schedule,,,505.86,,,fee schedule,,,,,,,,,428.40,,,percent of total billed charges,,,231.84,,,percent of total billed charges,,,,,,,,,,,,,,,495.94,,,fee schedule,,,,,,,,,,,,,,,495.94,,,fee schedule,,,,,,,,,495.94,,,fee schedule,,,,,,,,
PLATE BONE SACRAL 1 LEVEL 25MM,10373382,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6747.00,2024.10,2617.84,5734.95,,3306.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2833.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2617.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2867.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5060.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3373.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5734.95,,,percent of total billed charges,,,3036.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE SACRAL 1 LEVEL 25MM,10373382,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6747.00,2024.10,2833.74,5734.95,,3306.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2833.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3403.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2867.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5060.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3373.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5060.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5734.95,,,percent of total billed charges,,,3103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X9MM,10373383,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X9MM,10373383,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE TIBIA M/L 40MM FULL POR,10373384,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11512.00,3453.60,4466.66,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4466.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9785.20,,,percent of total billed charges,,,5180.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE TIBIA M/L 40MM FULL POR,10373384,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11512.00,3453.60,4835.04,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5806.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9785.20,,,percent of total billed charges,,,5295.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE TIB ATTUNE MD LG 35MM,10373385,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12994.00,3898.20,5041.67,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5041.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11044.9,,,percent of total billed charges,,,5847.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE TIB ATTUNE MD LG 35MM,10373385,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12994.00,3898.20,5457.48,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6554.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11044.9,,,percent of total billed charges,,,5977.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB PRESSFIT STR 16X60MM,10373386,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB PRESSFIT STR 16X60MM,10373386,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE ATTUNE SZ 5 12MM,10373387,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE ATTUNE SZ 5 12MM,10373387,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BRACE KNEE MUELLER HINGED LG X_55114503 X_PERFORMA,10373388,CDM,0274,RC,L1832,HCPCS,,,,,,inpatient,facility,,,166.00,49.80,64.41,141.10,,,,,,,,,,,,,,,,,,,,64.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,124.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.10,,,percent of total billed charges,,,74.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRACE KNEE MUELLER HINGED LG X_55114503 X_PERFORMA,10373388,CDM,0274,RC,L1832,HCPCS,,,,,,outpatient,facility,,,166.00,49.80,70.55,375.16,,,,,,,,163.34,,,fee schedule,,,,,,,,,83.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,343.62,,,fee schedule,,,166.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",166.61,,,fee schedule,,,375.16,,,fee schedule,,,,,,,,,163.34,,,fee schedule,,,,,,,,,70.55,,,percent of total billed charges,,Paid in addition to outpatient services ,338.64,,,fee schedule,,,124.5,,,percent of total billed charges,,,163.34,,,fee schedule,,,166.0,,,fee schedule,,,166.61,,,fee schedule,,,83.0,,,percent of total billed charges,,Paid in addition to outpatient services ,163.34,,,fee schedule,,,124.5,,,percent of total billed charges,,,166.0,,,fee schedule,,,166.61,,,fee schedule,,,,,,,,,141.10,,,percent of total billed charges,,,76.36,,,percent of total billed charges,,,,,,,,,,,,,,,163.34,,,fee schedule,,,,,,,,,,,,,,,163.34,,,fee schedule,,,,,,,,,163.34,,,fee schedule,,,,,,,,
PIN APEX TRANSFIX 5X6X300MM,10373391,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,751.00,225.30,291.39,638.35,,,,,,,,,,,,,,,,,,,,291.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,563.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,375.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.35,,,percent of total billed charges,,,337.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN APEX TRANSFIX 5X6X300MM,10373391,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,751.00,225.30,319.18,638.35,,,,,,,,,,,,,service not payable,,,,,,,378.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,319.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,375.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,563.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,345.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL RP CEM SZ4,10373392,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16864.00,5059.20,6543.23,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6543.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14334.4,,,percent of total billed charges,,,7588.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL RP CEM SZ4,10373392,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16864.00,5059.20,7082.88,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8506.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14334.4,,,percent of total billed charges,,,7757.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD SPINAL CORD MRI 90CM,10373393,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,20325.00,6097.50,7886.10,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7886.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17276.25,,,percent of total billed charges,,,9146.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD SPINAL CORD MRI 90CM,10373393,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,20325.00,6097.50,8536.5,17276.25,,9959.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8536.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10251.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8638.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15243.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10162.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15243.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17276.25,,,percent of total billed charges,,,9349.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE BREAST 650CC,10373394,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE BREAST 650CC,10373394,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE BREAST 700CC,10373395,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE BREAST 700CC,10373395,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER TISSUE BREAST 850CC,10373396,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6966.00,2089.80,2702.81,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2702.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5921.10,,,percent of total billed charges,,,3134.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER TISSUE BREAST 850CC,10373396,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6966.00,2089.80,2925.72,5921.10,,3413.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3513.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2960.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5224.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3483.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5921.10,,,percent of total billed charges,,,3204.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 255CC,10373397,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 255CC,10373397,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 285CC,10373398,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 285CC,10373398,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 310CC,10373399,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 310CC,10373399,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DIAG 6F NON TORQUE,10373400,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,63.00,18.90,26.77,53.55,,38.93,,,percent of total billed charges,,,,,,,,service not payable,30.74,,,percent of total billed charges,,,31.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,26.77,,,percent of total billed charges,,,,,,,,,47.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,31.5,,,percent of total billed charges,,,,,,,,service not payable,47.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,53.55,,,percent of total billed charges,,,28.98,,,percent of total billed charges,,,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Small Bowel Add,10375213,CDM,0320,RC,74248,CPT,,,,,,outpatient,facility,,,579.00,173.70,246.07,492.15,,357.82,,,percent of total billed charges,,,,,,,,service not payable,284.87,,,fee schedule,,,292.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,246.07,,,percent of total billed charges,,,,,,,,,434.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,289.5,,,percent of total billed charges,,,,,,,,service not payable,434.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,492.15,,,percent of total billed charges,,,266.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Small Bowel Add,10375213,CDM,0320,RC,74248,CPT,389,EAPG,,,,outpatient,facility,,,579.00,173.70,172.18,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,287.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Small Bowel Add,10375218,CDM,0320,RC,74248,CPT,,,,,,outpatient,facility,,,579.00,173.70,246.07,492.15,,357.82,,,percent of total billed charges,,,,,,,,service not payable,284.87,,,fee schedule,,,292.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,246.07,,,percent of total billed charges,,,,,,,,,434.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,289.5,,,percent of total billed charges,,,,,,,,service not payable,434.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,492.15,,,percent of total billed charges,,,266.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Small Bowel Add,10375218,CDM,0320,RC,74248,CPT,389,EAPG,,,,outpatient,facility,,,579.00,173.70,172.18,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,287.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Picc w/o Sub Port Image Guide>5,10375225,CDM,0940,RC,36573,CPT,,,,,,outpatient,facility,,,4010.00,1203.00,835.0,3408.5,,2478.18,,,percent of total billed charges,,,,,,,,,1956.88,,,percent of total billed charges,,,2022.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1704.25,,,percent of total billed charges,,,,,,,,,3007.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2005.0,,,percent of total billed charges,,,,,,,,,3007.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3408.5,,,percent of total billed charges,,,1844.60,,,percent of total billed charges,,,,,,,,,949.0,,,per diem,,,,,,,,,,,,,,,835.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Picc w/o Sub Port Image Guide>5,10375225,CDM,0940,RC,36573,CPT,05182,APC,,,,outpatient,facility,,,4010.00,1203.00,1428.90,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,1428.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,1428.90,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1428.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
Picc w/o Sub Port Image Guide>5,10375225,CDM,0940,RC,36573,CPT,75,EAPG,,,,outpatient,facility,,,4010.00,1203.00,1596.28,5479.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5479.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4657.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1596.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2337.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2571.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Pericardiocentesis,10375268,CDM,0481,RC,33016,CPT,,,,,,outpatient,facility,,,5097.00,1529.10,1562.0,4778.89,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,2570.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,3822.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,3822.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4332.45,,,percent of total billed charges,,,2344.62,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Pericardiocentesis,10375268,CDM,0481,RC,33016,CPT,05182,APC,,,,outpatient,facility,,,5097.00,1529.10,1428.90,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,1428.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,1428.90,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1428.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
Pericardiocentesis,10375268,CDM,0481,RC,33016,CPT,68,EAPG,,,,outpatient,facility,,,5097.00,1529.10,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Pericardial Drainage,10375269,CDM,0481,RC,33017,CPT,,,,,,outpatient,facility,,,1639.00,491.70,220.26,10719.0,,1639.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,10719.0,,,case rate,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,220.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,220.26,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,1229.25,,,percent of total billed charges,,,220.26,,,fee schedule,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Pericardial Drainage,10375269,CDM,0481,RC,33017,CPT,68,EAPG,,,,outpatient,facility,,,1639.00,491.70,1347.26,4506.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4506.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3830.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1449.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1347.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1481.99,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE ANKLE FUS ANT R 4H 105MM,10376219,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9344.00,2803.20,3625.47,7942.40,,4578.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3924.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3625.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3971.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7008.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4672.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7942.40,,,percent of total billed charges,,,4204.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANKLE FUS ANT R 4H 105MM,10376219,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9344.00,2803.20,3924.48,7942.40,,4578.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3924.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4713.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3971.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7008.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4672.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7008.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7942.40,,,percent of total billed charges,,,4298.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Radiopharm Quant per single area,10376305,CDM,0340,RC,78835,CPT,,,,,,outpatient,facility,,,639.00,191.70,271.57,543.15,,394.90,,,percent of total billed charges,,,,,,,,service not payable,314.39,,,fee schedule,,,322.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,271.57,,,percent of total billed charges,,,,,,,,,479.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,319.5,,,percent of total billed charges,,,,,,,,service not payable,479.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,543.15,,,percent of total billed charges,,,293.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Radiopharm Quant per single area,10376305,CDM,0340,RC,78835,CPT,331,EAPG,,,,outpatient,facility,,,639.00,191.70,534.64,1256.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1256.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1067.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,534.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,534.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,778.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,855.91,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Radiopharm Quant per single area,10376318,CDM,0340,RC,78835,CPT,,,,,,outpatient,facility,,,639.00,191.70,271.57,543.15,,394.90,,,percent of total billed charges,,,,,,,,service not payable,314.39,,,fee schedule,,,322.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,271.57,,,percent of total billed charges,,,,,,,,,479.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,319.5,,,percent of total billed charges,,,,,,,,service not payable,479.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,543.15,,,percent of total billed charges,,,293.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Radiopharm Quant per single area,10376318,CDM,0340,RC,78835,CPT,331,EAPG,,,,outpatient,facility,,,639.00,191.70,534.64,1256.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1256.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1067.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,534.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,534.64,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,778.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,855.91,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BSGI Gammagram Single Area 1 Day,10376483,CDM,0340,RC,78800,CPT,,,,,,outpatient,facility,,,2685.00,805.50,347.26,2282.25,,465.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,347.26,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BSGI Gammagram Single Area 1 Day,10376483,CDM,0340,RC,78800,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
BSGI Gammagram Single Area 1 Day,10376483,CDM,0340,RC,78800,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Nuclear Scan Single Area 1 Day,10376485,CDM,0340,RC,78800,CPT,,,,,,outpatient,facility,,,2685.00,805.50,347.26,2282.25,,465.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,347.26,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Nuclear Scan Single Area 1 Day,10376485,CDM,0340,RC,78800,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
Nuclear Scan Single Area 1 Day,10376485,CDM,0340,RC,78800,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Nuclear Scan Single Area Multi Day,10376489,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Nuclear Scan Single Area Multi Day,10376489,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
Nuclear Scan Single Area Multi Day,10376489,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tumor Scan Whole Body 1 Day,10376491,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Tumor Scan Whole Body 1 Day,10376491,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
Tumor Scan Whole Body 1 Day,10376491,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Bone Single Area 1 Day,10376493,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Bone Single Area 1 Day,10376493,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Bone Single Area 1 Day,10376493,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT PYP Single Area 1 Day,10376495,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT PYP Single Area 1 Day,10376495,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT PYP Single Area 1 Day,10376495,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Single Area 1 Day,10376497,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Single Area 1 Day,10376497,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Single Area 1 Day,10376497,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Nuclear Scan Whole Body Multi Day,10376499,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Nuclear Scan Whole Body Multi Day,10376499,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
Nuclear Scan Whole Body Multi Day,10376499,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tumor Scan Whole Body Multi Day,10376501,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Tumor Scan Whole Body Multi Day,10376501,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
Tumor Scan Whole Body Multi Day,10376501,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Bone Single Area 1 Day,10376503,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Bone Single Area 1 Day,10376503,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Bone Single Area 1 Day,10376503,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Infection Single Area 1 Day,10376505,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Infection Single Area 1 Day,10376505,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Infection Single Area 1 Day,10376505,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT PYP Single Area 1 Day,10376507,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT PYP Single Area 1 Day,10376507,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT PYP Single Area 1 Day,10376507,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Single Area 1 Day,10376509,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Single Area 1 Day,10376509,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Single Area 1 Day,10376509,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Y90 Mapping Single Area 1 Day,10376511,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Y90 Mapping Single Area 1 Day,10376511,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Y90 Mapping Single Area 1 Day,10376511,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Bone Multi Area 1 Day,10376513,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Bone Multi Area 1 Day,10376513,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Bone Multi Area 1 Day,10376513,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Multi Area 1 Day,10376515,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Multi Area 1 Day,10376515,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Multi Area 1 Day,10376515,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Single Area 2 Day,10376517,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Single Area 2 Day,10376517,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Single Area 2 Day,10376517,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Bone Multi Area 1 Day,10376519,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Bone Multi Area 1 Day,10376519,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
SPECT CT Bone Multi Area 1 Day,10376519,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Multi Area 1 Day,10376521,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Multi Area 1 Day,10376521,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
SPECT CT Multi Area 1 Day,10376521,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Single Area Multi Day,10376523,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Single Area Multi Day,10376523,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
SPECT CT Single Area Multi Day,10376523,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BSGI Gammagram Single Area 1 Day,10376599,CDM,0340,RC,78800,CPT,,,,,,outpatient,facility,,,2685.00,805.50,347.26,2282.25,,465.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,347.26,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BSGI Gammagram Single Area 1 Day,10376599,CDM,0340,RC,78800,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
BSGI Gammagram Single Area 1 Day,10376599,CDM,0340,RC,78800,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Nuclear Scan Single Area 1 Day,10376600,CDM,0340,RC,78800,CPT,,,,,,outpatient,facility,,,2685.00,805.50,347.26,2282.25,,465.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,347.26,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Nuclear Scan Single Area 1 Day,10376600,CDM,0340,RC,78800,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
Nuclear Scan Single Area 1 Day,10376600,CDM,0340,RC,78800,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Nuclear Scan Single Area Multi Day,10376602,CDM,0340,RC,78801,CPT,,,,,,outpatient,facility,,,2685.00,805.50,486.69,2282.25,,652.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,486.69,,,fee schedule,,,1354.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1141.13,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1342.5,,,percent of total billed charges,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2282.25,,,percent of total billed charges,,,1235.10,,,percent of total billed charges,,,,,,,,,864.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Nuclear Scan Single Area Multi Day,10376602,CDM,0340,RC,78801,CPT,05591,APC,,,,outpatient,facility,,,2685.00,805.50,369.61,885.04,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,810.63,,,fee schedule,,,369.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",393.05,,,fee schedule,,,885.04,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,798.88,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,369.61,,,fee schedule,,,393.05,,,fee schedule,,,,,,,,,385.34,,,fee schedule,,,,,,,,,369.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",393.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,,,,,,,385.34,,,fee schedule,,,,,,,,,389.19,,,fee schedule,,,,,,,,
Nuclear Scan Single Area Multi Day,10376602,CDM,0340,RC,78801,CPT,332,EAPG,,,,outpatient,facility,,,2685.00,805.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tumor Scan Whole Body 1 Day,10376603,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Tumor Scan Whole Body 1 Day,10376603,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
Tumor Scan Whole Body 1 Day,10376603,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Bone Single Area 1 Day,10376604,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Bone Single Area 1 Day,10376604,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Bone Single Area 1 Day,10376604,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT PYP Single Area 1 Day,10376605,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT PYP Single Area 1 Day,10376605,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT PYP Single Area 1 Day,10376605,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Single Area 1 Day,10376606,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Single Area 1 Day,10376606,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Single Area 1 Day,10376606,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Nuclear Scan Whole Body Multi Day,10376607,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Nuclear Scan Whole Body Multi Day,10376607,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
Nuclear Scan Whole Body Multi Day,10376607,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tumor Scan Whole Body Multi Day,10376608,CDM,0340,RC,78804,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,1142.91,7883.75,,1531.7,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,1142.91,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Tumor Scan Whole Body Multi Day,10376608,CDM,0340,RC,78804,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
Tumor Scan Whole Body Multi Day,10376608,CDM,0340,RC,78804,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Bone Single Area 1 Day,10376609,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Bone Single Area 1 Day,10376609,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Bone Single Area 1 Day,10376609,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Infection Single Area 1 Day,10376610,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Infection Single Area 1 Day,10376610,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Infection Single Area 1 Day,10376610,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT PYP Single Area 1 Day,10376611,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT PYP Single Area 1 Day,10376611,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT PYP Single Area 1 Day,10376611,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Single Area 1 Day,10376612,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Single Area 1 Day,10376612,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Single Area 1 Day,10376612,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Y90 Mapping Single Area 1 Day,10376613,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Y90 Mapping Single Area 1 Day,10376613,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT Y90 Mapping Single Area 1 Day,10376613,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Bone Multi Area 1 Day,10376614,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Bone Multi Area 1 Day,10376614,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Bone Multi Area 1 Day,10376614,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Multi Area 1 Day,10376615,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Multi Area 1 Day,10376615,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Multi Area 1 Day,10376615,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT Single Area 2 Day,10376616,CDM,0340,RC,78831,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,375.0,7883.75,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT Single Area 2 Day,10376616,CDM,0340,RC,78831,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT Single Area 2 Day,10376616,CDM,0340,RC,78831,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Bone Multi Area 1 Day,10376617,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Bone Multi Area 1 Day,10376617,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
SPECT CT Bone Multi Area 1 Day,10376617,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Multi Area 1 Day,10376618,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Multi Area 1 Day,10376618,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
SPECT CT Multi Area 1 Day,10376618,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT Single Area Multi Day,10376619,CDM,0340,RC,78832,CPT,,,,,,outpatient,facility,,,10522.00,3156.60,375.0,8943.70,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,5307.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.85,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5261.0,,,percent of total billed charges,,,,,,,,,7891.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.70,,,percent of total billed charges,,,4840.12,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT Single Area Multi Day,10376619,CDM,0340,RC,78832,CPT,05594,APC,,,,outpatient,facility,,,10522.00,3156.60,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
SPECT CT Single Area Multi Day,10376619,CDM,0340,RC,78832,CPT,332,EAPG,,,,outpatient,facility,,,10522.00,3156.60,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Fungal Smear,10378,CDM,0300,RC,87206,CPT,,,,,,outpatient,facility,,,64.00,19.20,5.12,54.40,,22.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.28,,,fee schedule,,,17.08,,,fee schedule,,,11.24,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.16,,,fee schedule,,,5.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.39,,,fee schedule,,,12.18,,,fee schedule,,,,,,,,,5.28,,,fee schedule,,,,,,,,,6.73,,,fee schedule,,,11.0,,,fee schedule,,,48.0,,,percent of total billed charges,,,5.28,,,fee schedule,,,5.12,,,fee schedule,,,5.39,,,fee schedule,,,7.92,,,fee schedule,,,5.28,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,5.39,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,5.93,,,fee schedule,,,5.28,,,fee schedule,,,,,,,,,5.23,,,fee schedule,,,5.28,,,fee schedule,,,,,,,,,5.33,,,fee schedule,,,,,,,,
Fungal Smear,10378,CDM,0300,RC,87206,CPT,396,EAPG,,,,outpatient,facility,,,64.00,19.20,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SRV FEE 15CC BIO DBM PTY 18MM,10379142,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,4988.00,1496.40,1935.34,4239.80,,,,,,,,,,,,,,,,,,,,1935.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2119.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3741.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2494.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4239.80,,,percent of total billed charges,,,2244.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SRV FEE 15CC BIO DBM PTY 18MM,10379142,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,4988.00,1496.40,2119.90,4239.80,,,,,,,,,,,,,service not payable,,,,,,,2515.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2119.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3741.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2494.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3741.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4239.80,,,percent of total billed charges,,,2294.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SRV FEE 15CC BIO DBM PTY 18MM,10379142,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,4988.00,1496.40,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP PL 6H 3.5X158MM LT,10379143,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8839.00,2651.70,3429.53,7513.15,,4331.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3712.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3429.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3756.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6629.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4419.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7513.15,,,percent of total billed charges,,,3977.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP PL 6H 3.5X158MM LT,10379143,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8839.00,2651.70,3712.38,7513.15,,4331.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3712.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4458.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3756.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6629.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4419.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6629.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7513.15,,,percent of total billed charges,,,4065.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUM PROX TI T2 8X260MM R,10379144,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5009.00,1502.70,1943.49,4257.65,,2454.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2103.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1943.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2128.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3756.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2504.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4257.65,,,percent of total billed charges,,,2254.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUM PROX TI T2 8X260MM R,10379144,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5009.00,1502.70,2103.78,4257.65,,2454.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2103.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2526.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2128.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3756.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2504.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3756.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4257.65,,,percent of total billed charges,,,2304.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET SLDBCK 48MM D,10379145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET SLDBCK 48MM D,10379145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Hepatitis C Virus (HCV) Antibody with Rflx to PCR,10379222,CDM,0300,RC,86803,CPT,,,,,,outpatient,facility,,,108.00,32.40,13.56,91.80,,60.64,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.98,,,fee schedule,,,45.25,,,fee schedule,,,29.76,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,29.54,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.26,,,fee schedule,,,32.25,,,fee schedule,,,,,,,,,13.98,,,fee schedule,,,,,,,,,18.53,,,fee schedule,,,29.11,,,fee schedule,,,81.0,,,percent of total billed charges,,,13.98,,,fee schedule,,,13.56,,,fee schedule,,,14.26,,,fee schedule,,,21.80,,,fee schedule,,,13.98,,,fee schedule,,,81.0,,,percent of total billed charges,,,,,,,,,14.26,,,fee schedule,,,,,,,,,91.80,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,,,,,,,15.70,,,fee schedule,,,13.98,,,fee schedule,,,,,,,,,13.84,,,fee schedule,,,13.98,,,fee schedule,,,,,,,,,14.12,,,fee schedule,,,,,,,,
Hepatitis C Virus (HCV) Antibody with Rflx to PCR,10379222,CDM,0300,RC,86803,CPT,394,EAPG,,,,outpatient,facility,,,108.00,32.40,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ATTUNE CRS FEMORAL RT SZ 3 CEM,10379514,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEMORAL RT SZ 3 CEM,10379514,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE ATTUNE SZ 3 8MM,10379515,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE ATTUNE SZ 3 8MM,10379515,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE BONE JAWS 18X18MM DISP,10379516,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5164.00,1549.20,2003.63,4389.40,,2530.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2168.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2003.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2194.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2582.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4389.40,,,percent of total billed charges,,,2323.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE BONE JAWS 18X18MM DISP,10379516,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5164.00,1549.20,2168.88,4389.40,,2530.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2168.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2604.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2194.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3873.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2582.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3873.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4389.40,,,percent of total billed charges,,,2375.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROTECTOR NERVE 3.5X20MM,10379517,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,7081.00,2124.30,2747.43,6018.85,,3469.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2974.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2747.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5310.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3540.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6018.85,,,percent of total billed charges,,,3186.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTECTOR NERVE 3.5X20MM,10379517,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,7081.00,2124.30,2974.02,6018.85,,3469.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2974.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3571.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3009.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5310.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3540.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5310.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6018.85,,,percent of total billed charges,,,3257.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE POW LK TI 3MM,10379518,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE POW LK TI 3MM,10379518,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE NITINOL 15WX12L DYNANIT,10379519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE NITINOL 15WX12L DYNANIT,10379519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR RT SZ5-6 9MM,10379520,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR RT SZ5-6 9MM,10379520,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB RT 6,10379521,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB RT 6,10379521,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR RT SZ 1-2 9MM,10379522,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR RT SZ 1-2 9MM,10379522,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB RT 3,10379523,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB RT 3,10379523,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG T10 4.1X38MM,10379526,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1732.00,519.60,672.02,1472.2,,,,,,,,,,,,,,,,,,,,672.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,736.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1299.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,866.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1472.2,,,percent of total billed charges,,,779.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG T10 4.1X38MM,10379526,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1732.00,519.60,736.10,1472.2,,,,,,,,,,,,,service not payable,,,,,,,873.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,736.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1299.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,866.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1299.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1472.2,,,percent of total billed charges,,,796.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK COMP BRD 5.0X173MM 9H,10379527,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7440.00,2232.00,2886.72,6324.0,,3645.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3124.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2886.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3162.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5580.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3720.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6324.0,,,percent of total billed charges,,,3348.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK COMP BRD 5.0X173MM 9H,10379527,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7440.00,2232.00,3124.80,6324.0,,3645.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3124.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3752.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3162.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5580.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3720.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5580.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6324.0,,,percent of total billed charges,,,3422.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE SPACER TIB MD,10379528,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE SPACER TIB MD,10379528,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PACING TEMPO TEMP CRV 6F,10379665,CDM,0278,RC,C1883,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PACING TEMPO TEMP CRV 6F,10379665,CDM,0278,RC,C1883,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 7.5 X 45MM,10379796,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 7.5 X 45MM,10379796,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE VITALLIUM 6X40MM,10379797,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1874.00,562.20,727.11,1592.90,,,,,,,,,,,,,,,,,,,,727.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1405.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,937.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1592.90,,,percent of total billed charges,,,843.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE VITALLIUM 6X40MM,10379797,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1874.00,562.20,796.45,1592.90,,,,,,,,,,,,,service not payable,,,,,,,945.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,796.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1405.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,937.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1405.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1592.90,,,percent of total billed charges,,,862.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ9 LT,10379798,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ9 LT,10379798,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP EXTERNAL SM 4X2.5MM,10379804,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2578.00,773.40,1000.26,2191.30,,,,,,,,,,,,,,,,,,,,1000.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1095.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1933.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1289.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2191.30,,,percent of total billed charges,,,1160.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP EXTERNAL SM 4X2.5MM,10379804,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2578.00,773.40,1095.65,2191.30,,,,,,,,,,,,,service not payable,,,,,,,1300.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1095.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1933.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1289.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1933.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2191.30,,,percent of total billed charges,,,1185.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
POST BICORT TI 4.5X47.5MM,10379805,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POST BICORT TI 4.5X47.5MM,10379805,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 200CC,10379812,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 200CC,10379812,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 225CC,10379813,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 225CC,10379813,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE SPYROMITE 2.0MM,10379814,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1784.00,535.20,692.19,1516.40,,,,,,,,,,,,,,,,,,,,692.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1516.40,,,percent of total billed charges,,,802.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE SPYROMITE 2.0MM,10379814,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1784.00,535.20,758.20,1516.40,,,,,,,,,,,,,service not payable,,,,,,,899.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1516.40,,,percent of total billed charges,,,820.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL SM UHP 400ML,10379815,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL SM UHP 400ML,10379815,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT FEM SHAFT 16-20.9CM,10379816,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,7196.00,2158.80,2792.05,6116.60,,3526.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3022.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2792.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3058.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5397.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3598.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6116.60,,,percent of total billed charges,,,3238.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT FEM SHAFT 16-20.9CM,10379816,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,7196.00,2158.80,3022.32,6116.60,,3526.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3022.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3629.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3058.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5397.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3598.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5397.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6116.60,,,percent of total billed charges,,,3310.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB ART BCS SZ 7-8 RT,10379817,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB ART BCS SZ 7-8 RT,10379817,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ5 11MM,10379818,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ5 11MM,10379818,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA SZ A38 11MM,10379819,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA SZ A38 11MM,10379819,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROSTHESIS 6MMX2.5CM,10379820,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9567.00,2870.10,3712.00,8131.95,,4687.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4018.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3712.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4065.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7175.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4783.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8131.95,,,percent of total billed charges,,,4305.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROSTHESIS 6MMX2.5CM,10379820,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9567.00,2870.10,4018.14,8131.95,,4687.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4018.14,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4825.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4065.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7175.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4783.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7175.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8131.95,,,percent of total billed charges,,,4400.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIS FEM NCB RT 9H 238MM,10379821,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIS FEM NCB RT 9H 238MM,10379821,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DRAIN COPE LOOP NEPH 10FR,10379825,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,955.00,286.50,405.88,811.75,,590.19,,,percent of total billed charges,,,,,,,,service not payable,466.04,,,percent of total billed charges,,,481.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,405.88,,,percent of total billed charges,,,,,,,,,716.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,477.5,,,percent of total billed charges,,,,,,,,service not payable,716.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,811.75,,,percent of total billed charges,,,439.30,,,percent of total billed charges,,,,,,,,,620.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,620.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DRAIN COPE LOOP NEPH 12FR,10379826,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,955.00,286.50,405.88,811.75,,590.19,,,percent of total billed charges,,,,,,,,service not payable,466.04,,,percent of total billed charges,,,481.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,405.88,,,percent of total billed charges,,,,,,,,,716.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,477.5,,,percent of total billed charges,,,,,,,,service not payable,716.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,811.75,,,percent of total billed charges,,,439.30,,,percent of total billed charges,,,,,,,,,620.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,620.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DRAIN COPE LOOP NEPH 8FR,10379827,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,1098.00,329.40,466.65,933.30,,678.56,,,percent of total billed charges,,,,,,,,service not payable,535.82,,,percent of total billed charges,,,553.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,466.65,,,percent of total billed charges,,,,,,,,,823.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,549.0,,,percent of total billed charges,,,,,,,,service not payable,823.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,933.30,,,percent of total billed charges,,,505.08,,,percent of total billed charges,,,,,,,,,713.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,713.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM SMPLCITI 46MM 17MM,10379830,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11779.00,3533.70,4570.25,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4570.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10012.15,,,percent of total billed charges,,,5300.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM SMPLCITI 46MM 17MM,10379830,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11779.00,3533.70,4947.18,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5941.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10012.15,,,percent of total billed charges,,,5418.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X85MM,10379831,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X85MM,10379831,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X90MM,10379832,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X90MM,10379832,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN ASIII TI 6.5X95MM,10379833,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN ASIII TI 6.5X95MM,10379833,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR LT SZ3-4 13MM,10379834,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR LT SZ3-4 13MM,10379834,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM OXIN NP BCS SZ3 LT,10379835,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM OXIN NP BCS SZ3 LT,10379835,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7.0X105MM,10379836,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7.0X105MM,10379836,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 7.0X90MM,10379837,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3038.00,911.40,1178.74,2582.30,,,,,,,,,,,,,,,,,,,,1178.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.30,,,percent of total billed charges,,,1367.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 7.0X90MM,10379837,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3038.00,911.40,1291.15,2582.30,,,,,,,,,,,,,service not payable,,,,,,,1532.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1291.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2278.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1519.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2278.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2582.30,,,percent of total billed charges,,,1397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK RE 3.25X25MM,10379838,CDM,0272,RC,C1759,HCPCS,,,,,,outpatient,facility,,,629.00,188.70,267.32,534.65,,388.72,,,percent of total billed charges,,,,,,,,service not payable,306.95,,,percent of total billed charges,,,317.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,267.32,,,percent of total billed charges,,,,,,,,,471.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,314.5,,,percent of total billed charges,,,,,,,,service not payable,471.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,534.65,,,percent of total billed charges,,,289.34,,,percent of total billed charges,,,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,408.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X100MM,10379842,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X100MM,10379842,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X105MM,10379843,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X105MM,10379843,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X110MM,10379844,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X110MM,10379844,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X35MM,10379845,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X35MM,10379845,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X45MM,10379846,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X45MM,10379846,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X55MM,10379847,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X55MM,10379847,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 8X60MM,10379848,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 8X60MM,10379848,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 6.5X115MM,10379849,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 6.5X115MM,10379849,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 6.5X120MM,10379850,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 6.5X120MM,10379850,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THR 6.5X110MM,10379851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THR 6.5X110MM,10379851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THR 6.5X115MM,10379852,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THR 6.5X115MM,10379852,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THR 6.5X120MM,10379853,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THR 6.5X120MM,10379853,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THR 6.5X60MM,10379854,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THR 6.5X60MM,10379854,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSX 340CC,10379855,CDM,0278,RC,L8600,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSX 340CC,10379855,CDM,0278,RC,L8600,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 2.25D 8.0,10379856,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 2.25D 8.0,10379856,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Hemorrhoidectomy intrnl by ligation other than ru,10380437,CDM,0450,RC,46946,CPT,,,,,,outpatient,facility,,,4884.00,1465.20,774.0,4151.40,,3018.31,,,percent of total billed charges,,,,,,,,,2383.39,,,percent of total billed charges,,,2463.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3663.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3663.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4151.40,,,percent of total billed charges,,,2246.64,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Hemorrhoidectomy intrnl by ligation other than ru,10380437,CDM,0450,RC,46946,CPT,05313,APC,,,,outpatient,facility,,,4884.00,1465.20,1261.27,6040.12,,,,,,,,2629.86,,,fee schedule,,,,,,,,,,,,,,,5532.32,,,fee schedule,,,1261.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",2682.46,,,fee schedule,,,6040.12,,,fee schedule,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,,,,,,,5452.14,,,fee schedule,,,,,,,,,2629.86,,,fee schedule,,,1261.27,,,fee schedule,,,2682.46,,,fee schedule,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,1261.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",2682.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,2656.05,,,fee schedule,,,,,,,,
Hemorrhoidectomy intrnl by ligation other than ru,10380437,CDM,0450,RC,46946,CPT,141,EAPG,,,,outpatient,facility,,,4884.00,1465.20,2092.24,5987.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5987.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5089.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3000.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3300.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HYDROSET INJECTABLE XT 10ML,10380509,CDM,0278,RC,C9362,HCPCS,,,,,,inpatient,facility,,,9937.00,2981.10,3855.56,8446.45,,4869.13,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4173.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3855.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4223.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7452.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4968.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8446.45,,,percent of total billed charges,,,4471.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROSET INJECTABLE XT 10ML,10380509,CDM,0278,RC,C9362,HCPCS,,,,,,outpatient,facility,,,9937.00,2981.10,4173.54,8446.45,,4869.13,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4173.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5012.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4223.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7452.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4968.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7452.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8446.45,,,percent of total billed charges,,,4571.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HYDROSET INJECTABLE XT 10ML,10380509,CDM,0278,RC,C9362,HCPCS,455,EAPG,,,,outpatient,facility,,,9937.00,2981.10,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 6 12MM,10380511,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 6 12MM,10380511,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STIMULATOR BRAIN ACTIVA PC,10380513,CDM,0278,RC,C1767,HCPCS,,,,,,inpatient,facility,,,40409.00,12122.70,15678.69,34347.65,,19800.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16971.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15678.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17173.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,30306.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34347.65,,,percent of total billed charges,,,18184.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STIMULATOR BRAIN ACTIVA PC,10380513,CDM,0278,RC,C1767,HCPCS,,,,,,outpatient,facility,,,40409.00,12122.70,16971.78,34347.65,,19800.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16971.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,20382.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17173.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,30306.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,30306.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34347.65,,,percent of total billed charges,,,18588.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROGRAMMER ACTIVA PATINET,10380514,CDM,0278,RC,C1787,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROGRAMMER ACTIVA PATINET,10380514,CDM,0278,RC,C1787,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW XIA 3 POLYAXIAL 4X45MM,10380515,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2677.00,803.10,1038.68,2275.45,,,,,,,,,,,,,,,,,,,,1038.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2007.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1338.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2275.45,,,percent of total billed charges,,,1204.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW XIA 3 POLYAXIAL 4X45MM,10380515,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2677.00,803.10,1137.72,2275.45,,,,,,,,,,,,,service not payable,,,,,,,1350.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1137.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2007.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1338.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2007.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2275.45,,,percent of total billed charges,,,1231.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH XENMATRIX 10X15CM,10380516,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,10927.00,3278.10,4239.68,9287.95,,5354.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4589.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4239.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4643.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8195.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5463.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9287.95,,,percent of total billed charges,,,4917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH XENMATRIX 10X15CM,10380516,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,10927.00,3278.10,4589.34,9287.95,,5354.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4589.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5511.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4643.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8195.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5463.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8195.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9287.95,,,percent of total billed charges,,,5026.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH XENMATRIX 10X10CM,10380517,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,7285.00,2185.50,2826.58,6192.25,,3569.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3059.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2826.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3096.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5463.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3642.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6192.25,,,percent of total billed charges,,,3278.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH XENMATRIX 10X10CM,10380517,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,7285.00,2185.50,3059.70,6192.25,,3569.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3059.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3674.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3096.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5463.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3642.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5463.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6192.25,,,percent of total billed charges,,,3351.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROXIMAL CUSTOM,10380518,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24762.00,7428.60,9607.66,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9607.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21047.70,,,percent of total billed charges,,,11142.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROXIMAL CUSTOM,10380518,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24762.00,7428.60,10400.04,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12489.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21047.70,,,percent of total billed charges,,,11390.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LAA Closure,10381422,CDM,0481,RC,33340,CPT,,,,,,outpatient,facility,,,46770.00,14031.00,721.38,39754.5,,13476.59,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,10719.0,,,case rate,,,23590.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,721.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,35077.5,,,percent of total billed charges,,,,,,,,service not payable,721.38,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,35077.5,,,percent of total billed charges,,,721.38,,,fee schedule,,,,,,,,service not payable,,,,,,,39754.5,,,percent of total billed charges,,,21514.20,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LAA Closure,10381422,CDM,0481,RC,33340,CPT,121,EAPG,,,,outpatient,facility,,,46770.00,14031.00,16810.68,37849.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37849.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,32171.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16810.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,18491.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Leadless Pacer Insertion,10381425,CDM,0481,RC,33274,CPT,,,,,,outpatient,facility,,,46808.00,14042.40,5463.36,40166.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,23609.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32559.0,,,case rate,,,,,,,,,35106.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38305.0,,,case rate,,,,,,,,,35106.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39786.80,,,percent of total billed charges,,,21531.68,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,,,,,,,,35346.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Leadless Pacer Insertion,10381425,CDM,0481,RC,33274,CPT,05224,APC,,,,outpatient,facility,,,46808.00,14042.40,17542.16,42004.34,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,38473.0,,,fee schedule,,,17542.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18612.75,,,fee schedule,,,42004.34,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,37915.42,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,17542.16,,,fee schedule,,,18612.75,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,17542.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",18612.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,18429.93,,,fee schedule,,,,,,,,
Leadless Pacer Insertion,10381425,CDM,0481,RC,33274,CPT,86,EAPG,,,,outpatient,facility,,,46808.00,14042.40,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Leadless Pacer Removal,10381428,CDM,0481,RC,33275,CPT,,,,,,outpatient,facility,,,8286.00,2485.80,3811.56,7120.36,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,4179.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,6214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7043.10,,,percent of total billed charges,,,3811.56,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Leadless Pacer Removal,10381428,CDM,0481,RC,33275,CPT,05183,APC,,,,outpatient,facility,,,8286.00,2485.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Leadless Pacer Removal,10381428,CDM,0481,RC,33275,CPT,87,EAPG,,,,outpatient,facility,,,8286.00,2485.80,8286.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8286.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ASD Repair,10381431,CDM,0481,RC,93580,CPT,,,,,,outpatient,facility,,,31204.00,9361.20,8952.83,28801.0,,11668.15,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8952.83,,,case rate,,,15739.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,23403.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,23403.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26523.40,,,percent of total billed charges,,,14353.84,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
ASD Repair,10381431,CDM,0481,RC,93580,CPT,05194,APC,,,,outpatient,facility,,,31204.00,9361.20,16517.06,39549.77,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,36224.79,,,fee schedule,,,16517.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17527.09,,,fee schedule,,,39549.77,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,35699.80,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,16517.06,,,fee schedule,,,17527.09,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,16517.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",17527.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,17354.92,,,fee schedule,,,,,,,,
ASD Repair,10381431,CDM,0481,RC,93580,CPT,121,EAPG,,,,outpatient,facility,,,31204.00,9361.20,16810.68,37849.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37849.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,32171.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,20990.07,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16810.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,18491.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intracardiac Echocardiology,10381435,CDM,0480,RC,93662,CPT,,,,,,outpatient,facility,,,3715.00,1114.50,1578.88,3157.75,,2295.87,,,percent of total billed charges,,,,,,,,service not payable,1812.92,,,percent of total billed charges,,,1873.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1578.88,,,percent of total billed charges,,,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,,,,,,,service not payable,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3157.75,,,percent of total billed charges,,,1708.90,,,percent of total billed charges,,,,,,,,,2075.0,,,per diem,,,,,,,,service not payable,,,,,,,1826.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Intracardiac Echocardiology,10381435,CDM,0480,RC,93662,CPT,81,EAPG,,,,outpatient,facility,,,3715.00,1114.50,630.02,1789.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1789.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1520.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Intracardiac Echocardiology,10381435,CDM,0480,RC,93662,CPT,84,EAPG,,,,outpatient,facility,,,3715.00,1114.50,4067.82,4474.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4067.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4474.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Vascular Access w/US,10381438,CDM,0402,RC,76937,CPT,,,,,,outpatient,facility,,,579.00,173.70,36.79,492.15,,49.31,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,36.79,,,fee schedule,,,292.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,246.07,,,percent of total billed charges,,,,,,,,,434.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,289.5,,,percent of total billed charges,,,,,,,,service not payable,434.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,492.15,,,percent of total billed charges,,,266.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Vascular Access w/US,10381438,CDM,0402,RC,76937,CPT,472,EAPG,,,,outpatient,facility,,,579.00,173.70,163.60,422.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,359.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,163.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,315.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,347.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Replace Leadless Pacer RT Vent w/Image,10381441,CDM,0481,RC,33274,CPT,,,,,,outpatient,facility,,,32110.00,9633.00,5463.36,40166.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,16196.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32559.0,,,case rate,,,,,,,,,24082.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38305.0,,,case rate,,,,,,,,,24082.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27293.5,,,percent of total billed charges,,,14770.6,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,,,,,,,,35346.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Replace Leadless Pacer RT Vent w/Image,10381441,CDM,0481,RC,33274,CPT,05224,APC,,,,outpatient,facility,,,32110.00,9633.00,17542.16,42004.34,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,38473.00,,,fee schedule,,,17542.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18612.75,,,fee schedule,,,42004.34,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,37915.42,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,17542.16,,,fee schedule,,,18612.75,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,17542.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",18612.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,18429.93,,,fee schedule,,,,,,,,
Replace Leadless Pacer RT Vent w/Image,10381441,CDM,0481,RC,33274,CPT,86,EAPG,,,,outpatient,facility,,,32110.00,9633.00,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
EVM - OP Visit Est. Pt for Eval/Mgmt and Provision,10381541,CDM,0761,RC,G2082,HCPCS,,,,,,outpatient,facility,,,2033.00,609.90,118.0,1728.05,,1256.39,,,percent of total billed charges,,,,,,,,,992.10,,,percent of total billed charges,,,1025.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.02,,,percent of total billed charges,,,,,,,,,1524.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1016.5,,,percent of total billed charges,,,,,,,,,1524.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1728.05,,,percent of total billed charges,,,935.18,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
EVM - OP Visit Est. Pt for Eval/Mgmt and Provision,10381541,CDM,0761,RC,G2082,HCPCS,01513,APC,,,,outpatient,facility,,,2033.00,609.90,1103.29,2533.98,,,,,,,,1103.29,,,fee schedule,,,,,,,,,,,,,,,2320.95,,,fee schedule,,,,,,,,,1125.36,,,fee schedule,,,2533.98,,,fee schedule,,,,,,,,,1103.29,,,fee schedule,,,,,,,,,,,,,,,2287.31,,,fee schedule,,,,,,,,,1103.29,,,fee schedule,,,,,,,,,1125.36,,,fee schedule,,,,,,,,,1103.29,,,fee schedule,,,,,,,,,,,,,,,1125.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1103.29,,,fee schedule,,,,,,,,,,,,,,,1103.29,,,fee schedule,,,,,,,,,1114.28,,,fee schedule,,,,,,,,
EVM - OP Visit Est. Pt for Eval/Mgmt and Provision,10381541,CDM,0761,RC,G2082,HCPCS,110,EAPG,,,,outpatient,facility,,,2033.00,609.90,582.80,2683.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2683.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2281.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.31,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,671.31,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,671.31,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,582.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,641.08,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
EVM -OP Visit Est. Pt for Eval/Mgmt and Provision,10381548,CDM,0761,RC,G2083,HCPCS,,,,,,outpatient,facility,,,2971.00,891.30,118.0,2525.35,,1836.08,,,percent of total billed charges,,,,,,,,,1449.85,,,percent of total billed charges,,,1498.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1262.67,,,percent of total billed charges,,,,,,,,,2228.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.5,,,percent of total billed charges,,,,,,,,,2228.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2525.35,,,percent of total billed charges,,,1366.66,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
EVM -OP Visit Est. Pt for Eval/Mgmt and Provision,10381548,CDM,0761,RC,G2083,HCPCS,01516,APC,,,,outpatient,facility,,,2971.00,891.30,1390.98,3194.74,,,,,,,,1390.98,,,fee schedule,,,,,,,,,,,,,,,2926.15,,,fee schedule,,,,,,,,,1418.8,,,fee schedule,,,3194.74,,,fee schedule,,,,,,,,,1390.98,,,fee schedule,,,,,,,,,,,,,,,2883.74,,,fee schedule,,,,,,,,,1390.98,,,fee schedule,,,,,,,,,1418.8,,,fee schedule,,,,,,,,,1390.98,,,fee schedule,,,,,,,,,,,,,,,1418.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1390.98,,,fee schedule,,,,,,,,,,,,,,,1390.98,,,fee schedule,,,,,,,,,1404.84,,,fee schedule,,,,,,,,
EVM -OP Visit Est. Pt for Eval/Mgmt and Provision,10381548,CDM,0761,RC,G2083,HCPCS,110,EAPG,,,,outpatient,facility,,,2971.00,891.30,582.80,2683.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2683.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2281.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.31,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,671.31,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,671.31,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,582.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,641.08,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANN TI 6.0X95MM,10381578,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 6.0X95MM,10381578,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T8 FT 2.7X30MM,10381579,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T8 FT 2.7X30MM,10381579,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE EBU4 SH 7F 90CM,10381580,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II RT SZ 4,10381755,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II RT SZ 4,10381755,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHORS BONE 3,10381757,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHORS BONE 3,10381757,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BIOINDUCTIVE LG,10381758,CDM,0278,RC,C9358,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BIOINDUCTIVE LG,10381758,CDM,0278,RC,C9358,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BIOINDUCTIVE LG,10381758,CDM,0278,RC,C9358,HCPCS,455,EAPG,,,,outpatient,facility,,,6556.00,1966.80,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 4 14MM,10381759,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 4 14MM,10381759,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM SHOULDER HUM MINI 9X83MM,10381760,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM SHOULDER HUM MINI 9X83MM,10381760,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7X60MMX130CM,10381764,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 8.0,10381773,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 8.0,10381773,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 8.5,10381774,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 8.5,10381774,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 9.0,10381775,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 9.0,10381775,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 9.5,10381776,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 9.5,10381776,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 10.0,10381777,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 10.0,10381777,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 15.0,10381778,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 15.0,10381778,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 15.5,10381779,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 15.5,10381779,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 19.5,10381780,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 19.5,10381780,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 21.5,10381781,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 21.5,10381781,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 22.0,10381782,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 22.0,10381782,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 22.5,10381783,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 22.5,10381783,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 23.0,10381784,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 23.0,10381784,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 24.0,10381785,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 24.0,10381785,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 25.0,10381786,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 25.0,10381786,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 25.5,10381787,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 25.5,10381787,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 28.0,10381788,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 28.0,10381788,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 29.0,10381789,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 29.0,10381789,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 29.5,10381790,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 29.5,10381790,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 30.0,10381791,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 30.0,10381791,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 31.0,10381792,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 31.0,10381792,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 1.5D 32.0,10381793,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 1.5D 32.0,10381793,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CEMENT ATTUNE 14X80MM,10382117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CEMENT ATTUNE 14X80MM,10382117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 2.5X28MM,10382123,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3086.00,925.80,1197.37,2623.10,,,,,,,,,,,,,,,,,,,,1197.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2314.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1543.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2623.10,,,percent of total billed charges,,,1388.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 2.5X28MM,10382123,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3086.00,925.80,1311.55,2623.10,,,,,,,,,,,,,service not payable,,,,,,,1556.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1311.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2314.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1543.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2314.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2623.10,,,percent of total billed charges,,,1419.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLCKG FT 2.7X36MM,10382124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLCKG FT 2.7X36MM,10382124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 11MM,10382126,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 11MM,10382126,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 12MM,10382127,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 12MM,10382127,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 13MM,10382128,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 13MM,10382128,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 14MM,10382129,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 14MM,10382129,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 16MM,10382130,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 16MM,10382130,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 18MM,10382131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 18MM,10382131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 2.3 X 18MM,10382132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 2.3 X 18MM,10382132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SS LK 2.7X14MM,10382134,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SS LK 2.7X14MM,10382134,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MINI-BLUE 2X17MM,10382135,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,226.00,67.80,87.69,192.10,,,,,,,,,,,,,,,,,,,,87.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.10,,,percent of total billed charges,,,101.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MINI-BLUE 2X17MM,10382135,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,226.00,67.80,96.05,192.10,,,,,,,,,,,,,service not payable,,,,,,,113.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,169.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,169.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.10,,,percent of total billed charges,,,103.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE POST LAT DIS HUM RT 15H,10382136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3984.00,1195.20,1545.79,3386.40,,,,,,,,,,,,,,,,,,,,1545.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2988.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1992.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3386.40,,,percent of total billed charges,,,1792.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE POST LAT DIS HUM RT 15H,10382136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3984.00,1195.20,1693.2,3386.40,,,,,,,,,,,,,service not payable,,,,,,,2009.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1693.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2988.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1992.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2988.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3386.40,,,percent of total billed charges,,,1832.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT OMEGA 32.5MM,10382137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,587.00,176.10,227.76,498.95,,,,,,,,,,,,,,,,,,,,227.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,440.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.95,,,percent of total billed charges,,,264.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT OMEGA 32.5MM,10382137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,587.00,176.10,249.47,498.95,,,,,,,,,,,,,service not payable,,,,,,,296.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,440.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,440.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.95,,,percent of total billed charges,,,270.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ANTERIOR TIBIALIS FOLD,10382138,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3979.00,1193.70,1543.85,3382.15,,,,,,,,,,,,,,,,,,,,1543.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1691.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2984.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1989.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3382.15,,,percent of total billed charges,,,1790.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ANTERIOR TIBIALIS FOLD,10382138,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3979.00,1193.70,1691.08,3382.15,,,,,,,,,,,,,service not payable,,,,,,,2007.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1691.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2984.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1989.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2984.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3382.15,,,percent of total billed charges,,,1830.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75D 11.0,10382139,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75D 11.0,10382139,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE ALLOSYNC 20X20X6.5MM,10382426,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE ALLOSYNC 20X20X6.5MM,10382426,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TI VA 3X34MM,10382427,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TI VA 3X34MM,10382427,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL TRI II CLUSTERHOKE 66G,10382428,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL TRI II CLUSTERHOKE 66G,10382428,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FT 2.4X12MM,10382429,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,576.00,172.80,223.49,489.60,,,,,,,,,,,,,,,,,,,,223.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,489.60,,,percent of total billed charges,,,259.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FT 2.4X12MM,10382429,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,576.00,172.80,244.80,489.60,,,,,,,,,,,,,service not payable,,,,,,,290.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,244.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,432.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,288.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,432.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,489.60,,,percent of total billed charges,,,264.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST 1.5X6MM,10382430,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,503.00,150.90,195.16,427.55,,,,,,,,,,,,,,,,,,,,195.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,377.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,251.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.55,,,percent of total billed charges,,,226.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST 1.5X6MM,10382430,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,503.00,150.90,213.78,427.55,,,,,,,,,,,,,service not payable,,,,,,,253.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,377.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,377.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,427.55,,,percent of total billed charges,,,231.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE WRST FUSN SHRT BND 123MM,10382431,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7152.00,2145.60,2774.98,6079.20,,3504.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3003.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2774.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3039.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5364.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3576.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6079.20,,,percent of total billed charges,,,3218.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE WRST FUSN SHRT BND 123MM,10382431,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7152.00,2145.60,3003.84,6079.20,,3504.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3003.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3607.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3039.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5364.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3576.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5364.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6079.20,,,percent of total billed charges,,,3289.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB STBplus  SZ2 20.0MM,10382432,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7363.00,2208.90,2856.84,6258.55,,3607.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3092.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2856.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3129.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5522.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3681.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6258.55,,,percent of total billed charges,,,3313.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB STBplus  SZ2 20.0MM,10382432,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7363.00,2208.90,3092.46,6258.55,,3607.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3092.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3713.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3129.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5522.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3681.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5522.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6258.55,,,percent of total billed charges,,,3386.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC TI 6.0X95X16MM,10382433,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC TI 6.0X95X16MM,10382433,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 7.5 X 40MM XIA,10382434,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 7.5 X 40MM XIA,10382434,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3 LEVEL 63MM,10382435,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3 LEVEL 63MM,10382435,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY FOLEY UROLOGY 14F,10382437,CDM,0272,RC,A4315,HCPCS,,,,,,outpatient,facility,,,139.00,41.70,59.08,118.15,,85.90,,,percent of total billed charges,,,,,,,,service not payable,67.83,,,percent of total billed charges,,,70.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.08,,,percent of total billed charges,,,,,,,,,104.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,69.5,,,percent of total billed charges,,,,,,,,service not payable,104.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,118.15,,,percent of total billed charges,,,63.94,,,percent of total billed charges,,,,,,,,,90.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,90.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cytomegalovirus (CMV) by Qualitative PCR,10382443,CDM,0300,RC,87496,CPT,,,,,,outpatient,facility,,,139.00,41.70,33.34,139.0,,139.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,104.25,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,104.25,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,118.15,,,percent of total billed charges,,,63.94,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Cytomegalovirus (CMV) by Qualitative PCR,10382443,CDM,0300,RC,87496,CPT,397,EAPG,,,,outpatient,facility,,,139.00,41.70,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHEATH DESTINATION 6F 149CM,10383121,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1650.00,495.00,701.25,1402.5,,1019.7,,,percent of total billed charges,,,,,,,,service not payable,805.20,,,percent of total billed charges,,,832.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,1237.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,825.0,,,percent of total billed charges,,,,,,,,service not payable,1237.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1402.5,,,percent of total billed charges,,,759.0,,,percent of total billed charges,,,,,,,,,1072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MINI TREK II RE 1.2X20MM X_1012268-20U X_ABBO,10383122,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE SAFARI2 SM CRV 275CM,10383124,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE SAFARI2 XS CRV 275CM,10383125,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB PROX LAT RT 4H 121MM,10383635,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,50381.00,15114.30,19547.83,42823.85,,24686.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21160.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,19547.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21411.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,37785.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25190.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42823.85,,,percent of total billed charges,,,22671.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB PROX LAT RT 4H 121MM,10383635,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,50381.00,15114.30,21160.02,42823.85,,24686.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21160.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,25412.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21411.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,37785.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25190.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,37785.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,42823.85,,,percent of total billed charges,,,23175.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE CSHD CNC 1-4MM 15CC,10383636,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,2273.00,681.90,881.92,1932.05,,,,,,,,,,,,,,,,,,,,881.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1932.05,,,percent of total billed charges,,,1022.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE CSHD CNC 1-4MM 15CC,10383636,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,2273.00,681.90,966.02,1932.05,,,,,,,,,,,,,service not payable,,,,,,,1146.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,966.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1704.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1136.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1704.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1932.05,,,percent of total billed charges,,,1045.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE CSHD CNC 1-4MM 15CC,10383636,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,2273.00,681.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS SZ7-8 LT 10MM,10383637,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ART BCS SZ7-8 LT 10MM,10383637,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II LT SZ9,10383638,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II LT SZ9,10383638,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SS 16THD 7.0X115MM,10383639,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1052.00,315.60,408.18,894.20,,,,,,,,,,,,,,,,,,,,408.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,,473.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SS 16THD 7.0X115MM,10383639,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1052.00,315.60,447.10,894.20,,,,,,,,,,,,,service not payable,,,,,,,530.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,447.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,789.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,526.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,789.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,,483.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS PENILE 700CX,10383640,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,30850.00,9255.00,11969.80,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11969.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26222.5,,,percent of total billed charges,,,13882.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS PENILE 700CX,10383640,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,30850.00,9255.00,12957.0,26222.5,,15116.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12957.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15560.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13111.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26222.5,,,percent of total billed charges,,,14191.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL BASE RP ATTUNE SZ6,10383641,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16864.00,5059.20,6543.23,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6543.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14334.4,,,percent of total billed charges,,,7588.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL BASE RP ATTUNE SZ6,10383641,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16864.00,5059.20,7082.88,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8506.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14334.4,,,percent of total billed charges,,,7757.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ6 8MM,10383642,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ6 8MM,10383642,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE AL 10 6F 100CM SH,10383644,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ACU-LOC 2 PROX NRW LT 65,10383813,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3327.00,998.10,1290.88,2827.95,,,,,,,,,,,,,,,,,,,,1290.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2495.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1663.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2827.95,,,percent of total billed charges,,,1497.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ACU-LOC 2 PROX NRW LT 65,10383813,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3327.00,998.10,1413.97,2827.95,,,,,,,,,,,,,service not payable,,,,,,,1678.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1413.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2495.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1663.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2495.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2827.95,,,percent of total billed charges,,,1530.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUMERAL 8.5 X 28CM,10383814,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4291.00,1287.30,1664.91,3647.35,,,,,,,,,,,,,,,,,,,,1664.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1823.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3218.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2145.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3647.35,,,percent of total billed charges,,,1930.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUMERAL 8.5 X 28CM,10383814,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4291.00,1287.30,1823.68,3647.35,,,,,,,,,,,,,service not payable,,,,,,,2164.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1823.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3218.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2145.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3218.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3647.35,,,percent of total billed charges,,,1973.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 12 T8,10383815,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 12 T8,10383815,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 14 T8,10383816,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 14 T8,10383816,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 16 T8,10383817,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 16 T8,10383817,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM TS 8 LT,10383818,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20606.00,6181.80,7995.13,17515.10,,10096.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8654.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7995.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8757.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15454.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10303.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17515.10,,,percent of total billed charges,,,9272.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM TS 8 LT,10383818,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20606.00,6181.80,8654.52,17515.10,,10096.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8654.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10393.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8757.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15454.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10303.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15454.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17515.10,,,percent of total billed charges,,,9478.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMT F-D 5MM SZ8 LT,10383819,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3544.00,1063.20,1375.07,3012.40,,,,,,,,,,,,,,,,,,,,1375.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3012.40,,,percent of total billed charges,,,1594.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMT F-D 5MM SZ8 LT,10383819,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3544.00,1063.20,1506.2,3012.40,,,,,,,,,,,,,service not payable,,,,,,,1787.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1506.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2658.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1772.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2658.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3012.40,,,percent of total billed charges,,,1630.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VENTED 7X30MM BC IF,10383863,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VENTED 7X30MM BC IF,10383863,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FUSION MED LT 4.0/5.5MM,10383865,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10635.00,3190.50,4126.38,9039.75,,5211.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4466.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4126.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4519.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7976.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5317.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9039.75,,,percent of total billed charges,,,4785.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FUSION MED LT 4.0/5.5MM,10383865,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10635.00,3190.50,4466.70,9039.75,,5211.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4466.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5364.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4519.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7976.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5317.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7976.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9039.75,,,percent of total billed charges,,,4892.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TEMP FIX,10383867,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,377.00,113.10,146.28,320.45,,,,,,,,,,,,,,,,,,,,146.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,188.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.45,,,percent of total billed charges,,,169.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TEMP FIX,10383867,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,377.00,113.10,160.22,320.45,,,,,,,,,,,,,service not payable,,,,,,,190.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,160.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,282.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,188.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,282.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,320.45,,,percent of total billed charges,,,173.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OSTEOPEN 4X20MM,10383868,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,842.00,252.60,326.70,715.70,,,,,,,,,,,,,,,,,,,,326.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.70,,,percent of total billed charges,,,378.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OSTEOPEN 4X20MM,10383868,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,842.00,252.60,357.85,715.70,,,,,,,,,,,,,service not payable,,,,,,,424.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,357.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,631.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,421.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,631.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,715.70,,,percent of total billed charges,,,387.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 4X40MM,10383869,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1482.00,444.60,575.02,1259.7,,,,,,,,,,,,,,,,,,,,575.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,629.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,741.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1259.7,,,percent of total billed charges,,,666.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 4X40MM,10383869,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1482.00,444.60,629.85,1259.7,,,,,,,,,,,,,service not payable,,,,,,,747.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,629.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,741.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1111.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1259.7,,,percent of total billed charges,,,681.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 4X50MM,10383870,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1482.00,444.60,575.02,1259.7,,,,,,,,,,,,,,,,,,,,575.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,629.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,741.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1259.7,,,percent of total billed charges,,,666.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 4X50MM,10383870,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1482.00,444.60,629.85,1259.7,,,,,,,,,,,,,service not payable,,,,,,,747.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,629.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,741.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1111.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1259.7,,,percent of total billed charges,,,681.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 4X60MM,10383871,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1482.00,444.60,575.02,1259.7,,,,,,,,,,,,,,,,,,,,575.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,629.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,741.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1259.7,,,percent of total billed charges,,,666.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 4X60MM,10383871,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1482.00,444.60,629.85,1259.7,,,,,,,,,,,,,service not payable,,,,,,,747.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,629.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1111.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,741.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1111.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1259.7,,,percent of total billed charges,,,681.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 5.5X20MM,10383872,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1579.00,473.70,612.65,1342.15,,,,,,,,,,,,,,,,,,,,612.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.15,,,percent of total billed charges,,,710.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 5.5X20MM,10383872,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1579.00,473.70,671.07,1342.15,,,,,,,,,,,,,service not payable,,,,,,,796.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1342.15,,,percent of total billed charges,,,726.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 5.5X45MM,10383873,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1579.00,473.70,612.65,1342.15,,,,,,,,,,,,,,,,,,,,612.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.15,,,percent of total billed charges,,,710.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 5.5X45MM,10383873,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1579.00,473.70,671.07,1342.15,,,,,,,,,,,,,service not payable,,,,,,,796.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1342.15,,,percent of total billed charges,,,726.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 5.5X55MM,10383874,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1579.00,473.70,612.65,1342.15,,,,,,,,,,,,,,,,,,,,612.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.15,,,percent of total billed charges,,,710.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 5.5X55MM,10383874,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1579.00,473.70,671.07,1342.15,,,,,,,,,,,,,service not payable,,,,,,,796.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1342.15,,,percent of total billed charges,,,726.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OP LK 5.5X60MM,10383875,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1579.00,473.70,612.65,1342.15,,,,,,,,,,,,,,,,,,,,612.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.15,,,percent of total billed charges,,,710.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OP LK 5.5X60MM,10383875,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1579.00,473.70,671.07,1342.15,,,,,,,,,,,,,service not payable,,,,,,,796.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,671.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1184.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,789.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1184.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1342.15,,,percent of total billed charges,,,726.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SPINE PEEK 4D 7X25X11MM,10383878,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6105.00,1831.50,2368.74,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5189.25,,,percent of total billed charges,,,2747.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SPINE PEEK 4D 7X25X11MM,10383878,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6105.00,1831.50,2564.10,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3079.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5189.25,,,percent of total billed charges,,,2808.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BROAD Y 5H 1.5MM,10383879,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4663.00,1398.90,1809.24,3963.55,,,,,,,,,,,,,,,,,,,,1809.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1981.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3497.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2331.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3963.55,,,percent of total billed charges,,,2098.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BROAD Y 5H 1.5MM,10383879,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4663.00,1398.90,1981.77,3963.55,,,,,,,,,,,,,service not payable,,,,,,,2352.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1981.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3497.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2331.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3497.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3963.55,,,percent of total billed charges,,,2144.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH CORON DIL TREK 3.25X6MM X_1012276-06 X_ABBOTT,10383965,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,733.00,219.90,311.52,623.05,,452.99,,,percent of total billed charges,,,,,,,,service not payable,357.70,,,percent of total billed charges,,,369.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,311.52,,,percent of total billed charges,,,,,,,,,549.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,366.5,,,percent of total billed charges,,,,,,,,service not payable,549.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,623.05,,,percent of total billed charges,,,337.18,,,percent of total billed charges,,,,,,,,,476.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,476.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW YUKON POLYAXIAL 3.5X28MM,10383966,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW YUKON POLYAXIAL 3.5X28MM,10383966,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 3.5X22MM,10383967,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 3.5X22MM,10383967,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR LAT OFFSET 10MM,10383968,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR LAT OFFSET 10MM,10383968,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD YUKON CNTAD OCT 3.5X35MM,10383969,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD YUKON CNTAD OCT 3.5X35MM,10383969,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX10MM CT,10383970,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX10MM CT,10383970,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX14MM CT,10383971,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX14MM CT,10383971,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX16MM CT,10383972,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX16MM CT,10383972,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX18MM CT,10383973,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX18MM CT,10383973,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX10MM LCK,10383974,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX10MM LCK,10383974,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN PROV FIX 2.5,10383976,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1033.00,309.90,400.80,878.05,,,,,,,,,,,,,,,,,,,,400.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,,464.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN PROV FIX 2.5,10383976,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1033.00,309.90,439.02,878.05,,,,,,,,,,,,,service not payable,,,,,,,521.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,,475.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB DISTAL 2.7MM 9H,10383977,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3726.00,1117.80,1445.69,3167.10,,,,,,,,,,,,,,,,,,,,1445.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2794.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1863.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3167.10,,,percent of total billed charges,,,1676.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB DISTAL 2.7MM 9H,10383977,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3726.00,1117.80,1583.55,3167.10,,,,,,,,,,,,,service not payable,,,,,,,1879.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1583.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2794.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1863.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2794.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3167.10,,,percent of total billed charges,,,1713.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE WRIST SS 2.4X170MM,10383978,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9432.00,2829.60,3659.62,8017.20,,4621.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3961.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3659.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4008.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7074.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4716.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8017.20,,,percent of total billed charges,,,4244.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE WRIST SS 2.4X170MM,10383978,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9432.00,2829.60,3961.44,8017.20,,4621.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3961.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4757.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4008.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7074.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4716.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7074.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8017.20,,,percent of total billed charges,,,4338.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT REV POST FEM SZ6 8MM,10383979,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT REV POST FEM SZ6 8MM,10383979,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT REV DIST FEM SZ6 4MM,10383980,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT REV DIST FEM SZ6 4MM,10383980,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT REV DIST FEM SZ6 12MM,10383981,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT REV DIST FEM SZ6 12MM,10383981,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE REV FEM 45MM,10383982,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11532.00,3459.60,4474.42,9802.20,,5650.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4843.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4474.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4901.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8649.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5766.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9802.20,,,percent of total billed charges,,,5189.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE REV FEM 45MM,10383982,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11532.00,3459.60,4843.44,9802.20,,5650.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4843.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5816.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4901.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8649.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5766.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8649.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9802.20,,,percent of total billed charges,,,5304.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REV RP SZ6 14MM,10383983,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV RP SZ6 14MM,10383983,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CRTX EVOS 3.5X13MM,10384047,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CRTX EVOS 3.5X13MM,10384047,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 3.5MM X 20MM EVOS,10384048,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 3.5MM X 20MM EVOS,10384048,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CRT EVOS S 3.5X24MM,10384049,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CRT EVOS S 3.5X24MM,10384049,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK SS ST 2.7X14MM,10384050,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK SS ST 2.7X14MM,10384050,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK SS ST 2.7X15MM,10384051,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK SS ST 2.7X15MM,10384051,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK SS ST 2.7X17MM,10384052,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK SS ST 2.7X17MM,10384052,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK SS ST 2.7X19MM,10384053,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK SS ST 2.7X19MM,10384053,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OSTEO 4.7MM X 28MM,10384054,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OSTEO 4.7MM X 28MM,10384054,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE OSTEO 4.7MM X 34MM,10384055,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE OSTEO 4.7MM X 34MM,10384055,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB MEDIAL DIST 3H,10384056,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3598.00,1079.40,1396.02,3058.30,,,,,,,,,,,,,,,,,,,,1396.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1529.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2698.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1799.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3058.30,,,percent of total billed charges,,,1619.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB MEDIAL DIST 3H,10384056,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3598.00,1079.40,1529.15,3058.30,,,,,,,,,,,,,service not payable,,,,,,,1814.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1529.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2698.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1799.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2698.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3058.30,,,percent of total billed charges,,,1655.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB LAT DIST 5H,10384057,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3320.00,996.00,1288.16,2822.0,,,,,,,,,,,,,,,,,,,,1288.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1411.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2490.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1660.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2822.0,,,percent of total billed charges,,,1494.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB LAT DIST 5H,10384057,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3320.00,996.00,1411.0,2822.0,,,,,,,,,,,,,service not payable,,,,,,,1674.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1411.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2490.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1660.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2490.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2822.0,,,percent of total billed charges,,,1527.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDOGRAFT EXCLUDR 26X12MM 18CM,10384058,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,24880.00,7464.00,9653.44,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9653.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21148.0,,,percent of total billed charges,,,11196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOGRAFT EXCLUDR 26X12MM 18CM,10384058,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,24880.00,7464.00,10449.6,21148.0,,12191.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10449.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12549.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21148.0,,,percent of total billed charges,,,11444.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE PERONEUS L SD,10384547,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,3987.00,1196.10,1546.96,3388.95,,,,,,,,,,,,,,,,,,,,1546.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1694.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2990.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1993.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.95,,,percent of total billed charges,,,1794.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE PERONEUS L SD,10384547,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,3987.00,1196.10,1694.47,3388.95,,,,,,,,,,,,,service not payable,,,,,,,2011.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1694.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2990.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1993.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2990.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3388.95,,,percent of total billed charges,,,1834.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FORCEP BIOPSY SPYBITE MAX,10384551,CDM,0272,RC,C1819,HCPCS,,,,,,outpatient,facility,,,2219.00,665.70,943.08,1886.15,,1371.34,,,percent of total billed charges,,,,,,,,service not payable,1082.87,,,percent of total billed charges,,,1119.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,943.08,,,percent of total billed charges,,,,,,,,,1664.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1109.5,,,percent of total billed charges,,,,,,,,service not payable,1664.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1886.15,,,percent of total billed charges,,,1020.74,,,percent of total billed charges,,,,,,,,,1442.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1442.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CTX 3.5 X 12,10384552,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CTX 3.5 X 12,10384552,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 2.7X 10 T8,10384553,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 2.7X 10 T8,10384553,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIBULA 2.7/3.5 L-D 5H,10384554,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3320.00,996.00,1288.16,2822.0,,,,,,,,,,,,,,,,,,,,1288.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1411.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2490.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1660.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2822.0,,,percent of total billed charges,,,1494.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIBULA 2.7/3.5 L-D 5H,10384554,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3320.00,996.00,1411.0,2822.0,,,,,,,,,,,,,service not payable,,,,,,,1674.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1411.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2490.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1660.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2490.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2822.0,,,percent of total billed charges,,,1527.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMPR FT 5.0 LG 42MM LGT,10384555,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2595.00,778.50,1006.86,2205.75,,,,,,,,,,,,,,,,,,,,1006.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.75,,,percent of total billed charges,,,1167.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMPR FT 5.0 LG 42MM LGT,10384555,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2595.00,778.50,1102.88,2205.75,,,,,,,,,,,,,service not payable,,,,,,,1308.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1102.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1297.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2205.75,,,percent of total billed charges,,,1193.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KWIRE .062 X 9.25,10384556,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KWIRE .062 X 9.25,10384556,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST HP 425-455CC,10384560,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST HP 425-455CC,10384560,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS MULTI FOCAL SZ 23,10384562,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS MULTI FOCAL SZ 23,10384562,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 4F 4X300,10384563,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,9016.00,2704.80,3831.80,7663.60,,5571.89,,,percent of total billed charges,,,,,,,,service not payable,4399.81,,,percent of total billed charges,,,4547.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3831.80,,,percent of total billed charges,,,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4508.0,,,percent of total billed charges,,,,,,,,service not payable,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7663.60,,,percent of total billed charges,,,4147.36,,,percent of total billed charges,,,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 5F 5X300,10384564,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,9016.00,2704.80,3831.80,7663.60,,5571.89,,,percent of total billed charges,,,,,,,,service not payable,4399.81,,,percent of total billed charges,,,4547.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3831.80,,,percent of total billed charges,,,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4508.0,,,percent of total billed charges,,,,,,,,service not payable,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7663.60,,,percent of total billed charges,,,4147.36,,,percent of total billed charges,,,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 6F 6X300,10384565,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,9016.00,2704.80,3831.80,7663.60,,5571.89,,,percent of total billed charges,,,,,,,,service not payable,4399.81,,,percent of total billed charges,,,4547.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3831.80,,,percent of total billed charges,,,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4508.0,,,percent of total billed charges,,,,,,,,service not payable,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7663.60,,,percent of total billed charges,,,4147.36,,,percent of total billed charges,,,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,5860.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE NAIL HUM 2.2X500MM,10384566,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1859.00,557.70,721.29,1580.15,,,,,,,,,,,,,,,,,,,,721.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1580.15,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDEWIRE NAIL HUM 2.2X500MM,10384566,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1859.00,557.70,790.07,1580.15,,,,,,,,,,,,,service not payable,,,,,,,937.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,790.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1394.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,929.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1394.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1580.15,,,percent of total billed charges,,,855.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW DISTAL NS 4.3X22MM,10384568,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW DISTAL NS 4.3X22MM,10384568,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW DISTAL NS 4.3X24MM,10384569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW DISTAL NS 4.3X24MM,10384569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW DISTAL NS 4.3X26MM,10384570,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2202.00,660.60,854.38,1871.7,,,,,,,,,,,,,,,,,,,,854.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,990.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW DISTAL NS 4.3X26MM,10384570,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2202.00,660.60,935.85,1871.7,,,,,,,,,,,,,service not payable,,,,,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PROX 5X44MM,10384571,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2202.00,660.60,854.38,1871.7,,,,,,,,,,,,,,,,,,,,854.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,990.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PROX 5X44MM,10384571,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2202.00,660.60,935.85,1871.7,,,,,,,,,,,,,service not payable,,,,,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PROX 5X48MM,10384572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2202.00,660.60,854.38,1871.7,,,,,,,,,,,,,,,,,,,,854.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.7,,,percent of total billed charges,,,990.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PROX 5X48MM,10384572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2202.00,660.60,935.85,1871.7,,,,,,,,,,,,,service not payable,,,,,,,1110.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,935.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1651.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1101.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1651.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1871.7,,,percent of total billed charges,,,1012.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL HUM LONG RT D8MM 270MM,10384573,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16260.00,4878.00,6308.88,13821.0,,7967.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6829.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6308.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6910.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13821.0,,,percent of total billed charges,,,7317.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL HUM LONG RT D8MM 270MM,10384573,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16260.00,4878.00,6829.20,13821.0,,7967.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6829.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8201.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6910.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12195.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13821.0,,,percent of total billed charges,,,7479.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 4X22MM,10384575,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2708.00,812.40,1050.70,2301.80,,,,,,,,,,,,,,,,,,,,1050.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,,1218.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 4X22MM,10384575,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2708.00,812.40,1150.90,2301.80,,,,,,,,,,,,,service not payable,,,,,,,1365.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,,1245.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE HIGH FF SIL SZ 4,10384576,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,289.00,86.70,30.36,245.65,,178.60,,,percent of total billed charges,,,,,,,,service not payable,141.03,,,percent of total billed charges,,,145.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,122.83,,,percent of total billed charges,,,,,,,,,216.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,,,,,,service not payable,216.75,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,245.65,,,percent of total billed charges,,,132.94,,,percent of total billed charges,,,,,,,,,187.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,187.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE DXTEND ECC D42MM,10384577,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE DXTEND ECC D42MM,10384577,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM SYN POR SZ8 12035MM,10384578,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM SYN POR SZ8 12035MM,10384578,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL CAN TFNA LT 125D 10X400MM,10384581,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL CAN TFNA LT 125D 10X400MM,10384581,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TFNA FENESTRATED 110MM,10384582,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TFNA FENESTRATED 110MM,10384582,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROSTIMULATOR,10384583,CDM,0278,RC,C1820,HCPCS,,,,,,inpatient,facility,,,22294.00,6688.20,8650.07,18949.90,,10924.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9363.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8650.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9474.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18949.90,,,percent of total billed charges,,,10032.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROSTIMULATOR,10384583,CDM,0278,RC,C1820,HCPCS,,,,,,outpatient,facility,,,22294.00,6688.20,9363.48,18949.90,,10924.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9363.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11245.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9474.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18949.90,,,percent of total billed charges,,,10255.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT LEAD TINED,10384584,CDM,0278,RC,C1897,HCPCS,,,,,,inpatient,facility,,,10442.00,3132.60,4051.50,8875.70,,5116.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4385.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4051.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4437.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7831.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5221.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8875.70,,,percent of total billed charges,,,4698.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT LEAD TINED,10384584,CDM,0278,RC,C1897,HCPCS,,,,,,outpatient,facility,,,10442.00,3132.60,4385.64,8875.70,,5116.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4385.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5266.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4437.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7831.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5221.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7831.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8875.70,,,percent of total billed charges,,,4803.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONTROL PATIENT REMOTE,10384585,CDM,0274,RC,C1787,HCPCS,,,,,,inpatient,facility,,,3501.00,1050.30,1358.39,2975.85,,,,,,,,,,,,,,,,,,,,1358.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1487.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2625.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1750.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2975.85,,,percent of total billed charges,,,1575.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONTROL PATIENT REMOTE,10384585,CDM,0274,RC,C1787,HCPCS,,,,,,outpatient,facility,,,3501.00,1050.30,1487.92,2975.85,,,,,,,,,,,,,service not payable,,,,,,,1765.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1487.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2625.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1750.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2625.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2975.85,,,percent of total billed charges,,,1610.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT LEAD TINED IMPLANT,10384586,CDM,0278,RC,C1897,HCPCS,,,,,,inpatient,facility,,,1793.00,537.90,695.68,1524.05,,,,,,,,,,,,,,,,,,,,695.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,762.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1344.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,896.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1524.05,,,percent of total billed charges,,,806.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT LEAD TINED IMPLANT,10384586,CDM,0278,RC,C1897,HCPCS,,,,,,outpatient,facility,,,1793.00,537.90,762.02,1524.05,,,,,,,,,,,,,service not payable,,,,,,,904.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,762.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1344.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,896.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1344.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1524.05,,,percent of total billed charges,,,824.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X110 NS,10384588,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1205.00,361.50,467.54,1024.25,,,,,,,,,,,,,,,,,,,,467.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.25,,,percent of total billed charges,,,542.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X110 NS,10384588,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1205.00,361.50,512.12,1024.25,,,,,,,,,,,,,service not payable,,,,,,,607.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,512.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,903.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,903.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1024.25,,,percent of total billed charges,,,554.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Transcath Retrieval Perc Intravasc FB w/image gui,10385214,CDM,0481,RC,37197,CPT,,,,,,outpatient,facility,,,8660.00,2598.00,3983.60,7361.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,4368.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,6495.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,6495.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7361.0,,,percent of total billed charges,,,3983.60,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Transcath Retrieval Perc Intravasc FB w/image gui,10385214,CDM,0481,RC,37197,CPT,05183,APC,,,,outpatient,facility,,,8660.00,2598.00,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Transcath Retrieval Perc Intravasc FB w/image gui,10385214,CDM,0481,RC,37197,CPT,77,EAPG,,,,outpatient,facility,,,8660.00,2598.00,5360.09,12010.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12010.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,10209.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6296.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,6925.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Streptococcus pneumoniae Antigen Urine,10385298,CDM,0300,RC,87899,CPT,,,,,,outpatient,facility,,,107.00,32.10,15.27,90.95,,50.96,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,15.75,,,fee schedule,,,38.03,,,fee schedule,,,33.51,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,33.26,,,fee schedule,,,15.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.07,,,fee schedule,,,36.32,,,fee schedule,,,,,,,,,15.75,,,fee schedule,,,,,,,,,20.64,,,fee schedule,,,32.78,,,fee schedule,,,80.25,,,percent of total billed charges,,,15.75,,,fee schedule,,,15.27,,,fee schedule,,,16.07,,,fee schedule,,,24.27,,,fee schedule,,,15.75,,,fee schedule,,,80.25,,,percent of total billed charges,,,,,,,,,16.07,,,fee schedule,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,17.68,,,fee schedule,,,15.75,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,15.75,,,fee schedule,,,,,,,,,15.91,,,fee schedule,,,,,,,,
Streptococcus pneumoniae Antigen Urine,10385298,CDM,0300,RC,87899,CPT,396,EAPG,,,,outpatient,facility,,,107.00,32.10,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Legionella Antigen - Urine,10385320,CDM,0300,RC,87449,CPT,,,,,,outpatient,facility,,,73.00,21.90,11.38,62.05,,50.96,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.74,,,fee schedule,,,38.03,,,fee schedule,,,24.99,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.80,,,fee schedule,,,11.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.97,,,fee schedule,,,27.07,,,fee schedule,,,,,,,,,11.74,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,24.44,,,fee schedule,,,54.75,,,percent of total billed charges,,,11.74,,,fee schedule,,,11.38,,,fee schedule,,,11.97,,,fee schedule,,,18.33,,,fee schedule,,,11.74,,,fee schedule,,,54.75,,,percent of total billed charges,,,,,,,,,11.97,,,fee schedule,,,,,,,,,62.05,,,percent of total billed charges,,,33.58,,,percent of total billed charges,,,,,,,,,13.18,,,fee schedule,,,11.74,,,fee schedule,,,,,,,,,11.62,,,fee schedule,,,11.74,,,fee schedule,,,,,,,,,11.86,,,fee schedule,,,,,,,,
Legionella Antigen - Urine,10385320,CDM,0300,RC,87449,CPT,396,EAPG,,,,outpatient,facility,,,73.00,21.90,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT PERIPH120CM CATH5FR 8X60,10385446,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 8X60,10385446,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN COVERED 7MM X 7.5 CM X_VBHR070702A X,10385456,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN COVERED 7MM X 7.5 CM X_VBHR070702A X,10385456,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN COVERED 8MM X 7.5CM X_VBHR080702A X_,10385457,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN COVERED 8MM X 7.5CM X_VBHR080702A X_,10385457,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CR CEM SZ2 LT X_1504-00-102 X_DEPUY,10385963,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11707.00,3512.10,4542.32,9950.95,,5736.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4916.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4542.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4975.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8780.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5853.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9950.95,,,percent of total billed charges,,,5268.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CR CEM SZ2 LT X_1504-00-102 X_DEPUY,10385963,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11707.00,3512.10,4916.94,9950.95,,5736.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4916.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5905.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4975.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8780.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5853.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8780.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9950.95,,,percent of total billed charges,,,5385.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ3 12MM X_1516-20-312,10385966,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ3 12MM X_1516-20-312,10385966,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ3 14MM X_1516-20-314,10385967,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ3 14MM X_1516-20-314,10385967,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ3 16MM X_1516-20-316,10385968,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ3 16MM X_1516-20-316,10385968,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ4 12MM X_1516-20-412,10385969,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ4 12MM X_1516-20-412,10385969,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ4 14MM X_1516-20-414,10385970,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ4 14MM X_1516-20-414,10385970,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ4 16MM X_1516-20-416,10385971,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ4 16MM X_1516-20-416,10385971,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ7 12MM X_1516-20-712,10385972,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ7 12MM X_1516-20-712,10385972,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ7 14MM X_1516-20-714,10385973,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ7 14MM X_1516-20-714,10385973,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ7 16MM X_1516-20-716,10385974,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ7 16MM X_1516-20-716,10385974,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ8 14MM X_1516-20-814,10385975,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ8 14MM X_1516-20-814,10385975,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ8 16MM X_1516-20-816,10385976,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ8 16MM X_1516-20-816,10385976,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ9 7MM X_1516-20-907 X,10385977,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ9 7MM X_1516-20-907 X,10385977,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ9 16MM X_1516-20-916,10385980,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ9 16MM X_1516-20-916,10385980,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 6MM X_1516-21-006,10385982,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 6MM X_1516-21-006,10385982,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 7MM X_1516-21-007,10385983,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 7MM X_1516-21-007,10385983,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 8MM X_1516-21-008,10385984,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 8MM X_1516-21-008,10385984,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 12MM X_1516-21-012,10385985,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 12MM X_1516-21-012,10385985,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 14MM X_1516-21-014,10385986,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 14MM X_1516-21-014,10385986,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 16MM X_1516-21-016,10385987,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ10 16MM X_1516-21-016,10385987,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 5MM X_1516-20-105 X,10385988,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 5MM X_1516-20-105 X,10385988,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 6MM X_1516-20-106 X,10385989,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 6MM X_1516-20-106 X,10385989,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 7MM X_1516-20-107 X,10385990,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 7MM X_1516-20-107 X,10385990,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 8MM X_1516-20-108 X,10385991,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 8MM X_1516-20-108 X,10385991,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 10MM X_1516-20-110,10385992,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 10MM X_1516-20-110,10385992,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 14MM X_1516-20-114,10385994,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 14MM X_1516-20-114,10385994,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 16MM X_1516-20-116,10385995,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 16MM X_1516-20-116,10385995,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 5MM X_1516-20-205 X,10385996,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 5MM X_1516-20-205 X,10385996,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 6MM X_1516-20-206 X,10385997,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 6MM X_1516-20-206 X,10385997,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 7MM X_1516-20-207 X,10385998,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 7MM X_1516-20-207 X,10385998,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 8MM X_1516-20-208 X,10385999,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 8MM X_1516-20-208 X,10385999,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 10MM X_1516-20-210,10386000,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 10MM X_1516-20-210,10386000,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 12MM X_1516-20-212,10386001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 12MM X_1516-20-212,10386001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 14MM X_1516-20-214,10386002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 14MM X_1516-20-214,10386002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 16MM X_1516-20-216,10386003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ2 16MM X_1516-20-216,10386003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 5MM X_1516-40-105 X,10386004,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 5MM X_1516-40-105 X,10386004,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 6MM X_1516-40-106 X,10386005,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 6MM X_1516-40-106 X,10386005,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 7MM X_1516-40-107 X,10386006,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 7MM X_1516-40-107 X,10386006,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 8MM X_1516-40-108 X,10386007,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 8MM X_1516-40-108 X,10386007,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 12MM X_1516-40-112,10386008,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 12MM X_1516-40-112,10386008,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 16MM X_1516-40-116,10386009,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 16MM X_1516-40-116,10386009,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 18MM X_1516-40-118,10386010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR FB SZ1 18MM X_1516-40-118,10386010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS FB SZ2 6MM,10386011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS FB SZ2 6MM,10386011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ5 7MM X_1516-30-507 X,10386030,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ5 7MM X_1516-30-507 X,10386030,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ6 5MM X_1516-30-605 X,10386036,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4079.00,1223.70,1582.65,3467.15,,,,,,,,,,,,,,,,,,,,1582.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1733.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3059.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2039.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3467.15,,,percent of total billed charges,,,1835.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ6 5MM X_1516-30-605 X,10386036,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4079.00,1223.70,1733.58,3467.15,,,,,,,,,,,,,service not payable,,,,,,,2057.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1733.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3059.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2039.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3059.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3467.15,,,percent of total billed charges,,,1876.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ6 10MM X_1516-30-610,10386040,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ6 10MM X_1516-30-610,10386040,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ7 5MM X_1516-30-705 X,10386044,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ7 5MM X_1516-30-705 X,10386044,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR RP SZ7 6MM,10386045,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR RP SZ7 6MM,10386045,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ7 10MM X_1516-30-710,10386048,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5394.00,1618.20,2092.87,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2092.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.90,,,percent of total billed charges,,,2427.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ7 10MM X_1516-30-710,10386048,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5394.00,1618.20,2265.48,4584.90,,2643.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2265.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2720.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2292.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4045.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2697.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4045.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4584.90,,,percent of total billed charges,,,2481.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ8 10MM X_1516-30-810,10386055,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6361.00,1908.30,2468.07,5406.85,,3116.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2671.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2468.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2703.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4770.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5406.85,,,percent of total billed charges,,,2862.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ8 10MM X_1516-30-810,10386055,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6361.00,1908.30,2671.62,5406.85,,3116.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2671.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3208.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2703.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4770.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4770.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5406.85,,,percent of total billed charges,,,2926.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ10 10MM X_1516-31-010,10386084,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4249.00,1274.70,1648.61,3611.65,,,,,,,,,,,,,,,,,,,,1648.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3611.65,,,percent of total billed charges,,,1912.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ10 10MM X_1516-31-010,10386084,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4249.00,1274.70,1805.82,3611.65,,,,,,,,,,,,,service not payable,,,,,,,2143.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3611.65,,,percent of total billed charges,,,1954.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ2 6MM X_1516-30-206 X,10386089,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4249.00,1274.70,1648.61,3611.65,,,,,,,,,,,,,,,,,,,,1648.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3611.65,,,percent of total billed charges,,,1912.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL ATTUNE CR RP SZ2 6MM X_1516-30-206 X,10386089,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4249.00,1274.70,1805.82,3611.65,,,,,,,,,,,,,service not payable,,,,,,,2143.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3611.65,,,percent of total billed charges,,,1954.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT FEMORAL ARTERY <21,10386817,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,13841.00,4152.30,5370.31,11764.85,,6782.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5813.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5370.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5882.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10380.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6920.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11764.85,,,percent of total billed charges,,,6228.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT FEMORAL ARTERY <21,10386817,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,13841.00,4152.30,5813.22,11764.85,,6782.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5813.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6981.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5882.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10380.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6920.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10380.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11764.85,,,percent of total billed charges,,,6366.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ 4 16MM,10386818,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ 4 16MM,10386818,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ 7 12MM,10386819,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ 7 12MM,10386819,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RELINE COCR 5.5MMX120MM,10386820,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1050.00,315.00,407.40,892.5,,,,,,,,,,,,,,,,,,,,407.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,525.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.5,,,percent of total billed charges,,,472.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RELINE COCR 5.5MMX120MM,10386820,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1050.00,315.00,446.25,892.5,,,,,,,,,,,,,service not payable,,,,,,,529.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,787.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,525.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,787.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,892.5,,,percent of total billed charges,,,483.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STD 48X21MM,10386821,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11779.00,3533.70,4570.25,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4570.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10012.15,,,percent of total billed charges,,,5300.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STD 48X21MM,10386821,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11779.00,3533.70,4947.18,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5941.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10012.15,,,percent of total billed charges,,,5418.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1 LEVEL 20MM OZARK,10386822,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1 LEVEL 20MM OZARK,10386822,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS COMP 4X55MM,10386823,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS COMP 4X55MM,10386823,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLS COMP 7X85MM,10386824,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3597.00,1079.10,1395.64,3057.45,,,,,,,,,,,,,,,,,,,,1395.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1528.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2697.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1798.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3057.45,,,percent of total billed charges,,,1618.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLS COMP 7X85MM,10386824,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3597.00,1079.10,1528.72,3057.45,,,,,,,,,,,,,service not payable,,,,,,,1814.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1528.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2697.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1798.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2697.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3057.45,,,percent of total billed charges,,,1654.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Mumps Virus by PCR,10386836,CDM,0300,RC,87798,CPT,,,,,,outpatient,facility,,,202.00,60.60,33.34,171.70,,149.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,151.5,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,151.5,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,171.70,,,percent of total billed charges,,,92.92,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Mumps Virus by PCR,10386836,CDM,0300,RC,87798,CPT,397,EAPG,,,,outpatient,facility,,,202.00,60.60,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10387166,CDM,0360,RC,33419,CPT,,,,,,outpatient,facility,,,5956.00,1786.80,1106.0,5956.0,,5956.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,3004.21,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,4467.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,4467.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5062.60,,,percent of total billed charges,,,2739.76,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10387166,CDM,0360,RC,33419,CPT,121,EAPG,,,,outpatient,facility,,,5956.00,1786.80,5956.0,37849.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37849.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,32171.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5956.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5956.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5956.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16810.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,18491.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SP Exam,10387168,CDM,0360,RC,33418,CPT,,,,,,outpatient,facility,,,16293.00,4887.90,1574.44,13849.05,,7119.04,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,8218.19,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,1574.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,12219.75,,,percent of total billed charges,,,,,,,,service not payable,1574.44,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,12219.75,,,percent of total billed charges,,,1574.44,,,fee schedule,,,,,,,,service not payable,,,,,,,13849.05,,,percent of total billed charges,,,7494.78,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10387168,CDM,0360,RC,33418,CPT,121,EAPG,,,,outpatient,facility,,,16293.00,4887.90,16293.0,37849.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37849.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,32171.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16293.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16293.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16293.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16810.68,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,18491.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Transferrin Profile - FH,10387626,CDM,0300,RC,83540,CPT,,,,,,outpatient,facility,,,45.00,13.50,6.15,38.25,,27.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.34,,,fee schedule,,,20.53,,,fee schedule,,,13.49,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.39,,,fee schedule,,,6.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.47,,,fee schedule,,,14.62,,,fee schedule,,,,,,,,,6.34,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.20,,,fee schedule,,,33.75,,,percent of total billed charges,,,6.34,,,fee schedule,,,6.15,,,fee schedule,,,6.47,,,fee schedule,,,9.92,,,fee schedule,,,6.34,,,fee schedule,,,33.75,,,percent of total billed charges,,,,,,,,,6.47,,,fee schedule,,,,,,,,,38.25,,,percent of total billed charges,,,20.70,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.40,,,fee schedule,,,,,,,,
Transferrin Profile - FH,10387626,CDM,0300,RC,83540,CPT,402,EAPG,,,,outpatient,facility,,,45.00,13.50,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Group B Strep by PCR,10387644,CDM,0300,RC,87653,CPT,,,,,,outpatient,facility,,,419.00,125.70,33.34,356.15,,149.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,314.25,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,314.25,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,356.15,,,percent of total billed charges,,,192.74,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Group B Strep by PCR,10387644,CDM,0300,RC,87653,CPT,397,EAPG,,,,outpatient,facility,,,419.00,125.70,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SYNTHES 2.0 X 12MM SCREW WENDT 201.932,10387989,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,326.00,97.80,126.49,277.10,,,,,,,,,,,,,,,,,,,,126.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,244.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.10,,,percent of total billed charges,,,146.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYNTHES 2.0 X 12MM SCREW WENDT 201.932,10387989,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,326.00,97.80,138.55,277.10,,,,,,,,,,,,,service not payable,,,,,,,164.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,244.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,163.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,244.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,277.10,,,percent of total billed charges,,,149.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRSNG SILICONE FOAM AG 4X4,10388131,CDM,0272,RC,A6209,HCPCS,,,,,,outpatient,facility,,,52.00,15.60,22.10,44.20,,32.14,,,percent of total billed charges,,,,,,,,service not payable,25.38,,,percent of total billed charges,,,26.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,22.10,,,percent of total billed charges,,,,,,,,,39.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,26.0,,,percent of total billed charges,,,,,,,,service not payable,39.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,44.20,,,percent of total billed charges,,,23.92,,,percent of total billed charges,,,,,,,,,33.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,33.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL RECON LFT A3X400MM X125D,10388132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6253.00,1875.90,2426.16,5315.05,,3063.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2626.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2426.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2657.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4689.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3126.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5315.05,,,percent of total billed charges,,,2813.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL RECON LFT A3X400MM X125D,10388132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6253.00,1875.90,2626.26,5315.05,,3063.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2626.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3154.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2657.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4689.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3126.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4689.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5315.05,,,percent of total billed charges,,,2876.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 SZ4 13MM,10388145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 SZ4 13MM,10388145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STIMULATOR EXTERNAL TRIAL,10388157,CDM,0278,RC,C1767,HCPCS,,,,,,inpatient,facility,,,1203.00,360.90,466.76,1022.55,,,,,,,,,,,,,,,,,,,,466.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,902.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,601.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.55,,,percent of total billed charges,,,541.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STIMULATOR EXTERNAL TRIAL,10388157,CDM,0278,RC,C1767,HCPCS,,,,,,outpatient,facility,,,1203.00,360.90,511.27,1022.55,,,,,,,,,,,,,service not payable,,,,,,,606.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,511.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,601.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,902.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1022.55,,,percent of total billed charges,,,553.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT LEAD PNE IMPLANT,10388158,CDM,0278,RC,C1883,HCPCS,,,,,,inpatient,facility,,,1421.00,426.30,551.35,1207.85,,,,,,,,,,,,,,,,,,,,551.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1065.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,710.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.85,,,percent of total billed charges,,,639.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT LEAD PNE IMPLANT,10388158,CDM,0278,RC,C1883,HCPCS,,,,,,outpatient,facility,,,1421.00,426.30,603.92,1207.85,,,,,,,,,,,,,service not payable,,,,,,,716.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,603.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1065.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,710.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1065.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1207.85,,,percent of total billed charges,,,653.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD PNE,10388159,CDM,0278,RC,C1897,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD PNE,10388159,CDM,0278,RC,C1897,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE REV 35MM,10388161,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11512.00,3453.60,4466.66,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4466.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9785.20,,,percent of total billed charges,,,5180.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE REV 35MM,10388161,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11512.00,3453.60,4835.04,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5806.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9785.20,,,percent of total billed charges,,,5295.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE ATTUNE REV TIB 45MM,10388162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12994.00,3898.20,5041.67,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5041.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11044.9,,,percent of total billed charges,,,5847.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE ATTUNE REV TIB 45MM,10388162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12994.00,3898.20,5457.48,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6554.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11044.9,,,percent of total billed charges,,,5977.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REV PLATFORM SZ5 10MM,10388163,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV PLATFORM SZ5 10MM,10388163,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE AUGMENT REV FEM SZ5 4MM,10388164,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE AUGMENT REV FEM SZ5 4MM,10388164,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT REV FEM SZ5 8MM,10388165,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT REV FEM SZ5 8MM,10388165,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE 15 X 15 X 15MM,10388166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5003.00,1500.90,1941.16,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1941.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4252.55,,,percent of total billed charges,,,2251.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE 15 X 15 X 15MM,10388166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5003.00,1500.90,2101.26,4252.55,,2451.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2101.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2523.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2126.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3752.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2501.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3752.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4252.55,,,percent of total billed charges,,,2301.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EVOLVE 6.5MM 4,10388167,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6983.00,2094.90,2709.40,5935.55,,3421.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2932.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2709.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2967.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5237.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3491.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5935.55,,,percent of total billed charges,,,3142.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EVOLVE 6.5MM 4,10388167,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6983.00,2094.90,2932.86,5935.55,,3421.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2932.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3522.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2967.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5237.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3491.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5237.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5935.55,,,percent of total billed charges,,,3212.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T2 FT 5X27MM,10388168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,932.00,279.60,361.62,792.20,,,,,,,,,,,,,,,,,,,,361.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792.20,,,percent of total billed charges,,,419.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T2 FT 5X27MM,10388168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,932.00,279.60,396.10,792.20,,,,,,,,,,,,,service not payable,,,,,,,470.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,699.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,792.20,,,percent of total billed charges,,,428.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL ANKLE RT 10X150MM,10388169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6776.00,2032.80,2629.09,5759.60,,3320.24,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2845.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2629.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5082.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3388.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5759.60,,,percent of total billed charges,,,3049.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL ANKLE RT 10X150MM,10388169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6776.00,2032.80,2845.92,5759.60,,3320.24,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2845.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3417.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5082.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3388.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5082.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5759.60,,,percent of total billed charges,,,3116.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5X35MM,10388170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,980.00,294.00,380.24,833.0,,,,,,,,,,,,,,,,,,,,380.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,416.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,735.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.0,,,percent of total billed charges,,,441.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5X35MM,10388170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,980.00,294.00,416.5,833.0,,,,,,,,,,,,,service not payable,,,,,,,494.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,416.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,735.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,490.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,735.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,833.0,,,percent of total billed charges,,,450.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP HL 4X24MM,10388171,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2555.00,766.50,991.34,2171.75,,,,,,,,,,,,,,,,,,,,991.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2171.75,,,percent of total billed charges,,,1149.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP HL 4X24MM,10388171,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2555.00,766.50,1085.88,2171.75,,,,,,,,,,,,,service not payable,,,,,,,1288.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1916.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1277.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1916.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2171.75,,,percent of total billed charges,,,1175.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HAND 2.3MM LCKG L 6H,10388173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1550.00,465.00,601.40,1317.5,,,,,,,,,,,,,,,,,,,,601.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1162.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1317.5,,,percent of total billed charges,,,697.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HAND 2.3MM LCKG L 6H,10388173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1550.00,465.00,658.75,1317.5,,,,,,,,,,,,,service not payable,,,,,,,781.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,658.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1162.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1162.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1317.5,,,percent of total billed charges,,,713.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INPACT 6MMX200MMX130CM,10388174,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6119.00,1835.70,2600.57,5201.15,,3781.54,,,percent of total billed charges,,,,,,,,service not payable,2986.07,,,percent of total billed charges,,,3086.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2600.57,,,percent of total billed charges,,,,,,,,,4589.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3059.5,,,percent of total billed charges,,,,,,,,service not payable,4589.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5201.15,,,percent of total billed charges,,,2814.74,,,percent of total billed charges,,,,,,,,,3977.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3977.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 6F 0.035INX7X120MMX135CM,10388175,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,937.00,281.10,398.23,796.45,,579.07,,,percent of total billed charges,,,,,,,,service not payable,457.26,,,percent of total billed charges,,,472.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,398.23,,,percent of total billed charges,,,,,,,,,702.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,468.5,,,percent of total billed charges,,,,,,,,service not payable,702.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,796.45,,,percent of total billed charges,,,431.02,,,percent of total billed charges,,,,,,,,,609.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,609.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DYNANITE PIP STR 14MM W/INSTR,10388176,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DYNANITE PIP STR 14MM W/INSTR,10388176,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BRIGADE DISTRACTION 12MM,10388177,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BRIGADE DISTRACTION 12MM,10388177,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BRIGADE DISTRACTION 14MM,10388178,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BRIGADE DISTRACTION 14MM,10388178,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MODULUS C 9X17X14MM 7,10388179,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MODULUS C 9X17X14MM 7,10388179,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HELIX REV LVL 1 26MM,10388180,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HELIX REV LVL 1 26MM,10388180,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 60X4MM,10388363,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,932.00,279.60,361.62,792.20,,,,,,,,,,,,,,,,,,,,361.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792.20,,,percent of total billed charges,,,419.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 60X4MM,10388363,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,932.00,279.60,396.10,792.20,,,,,,,,,,,,,service not payable,,,,,,,470.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,699.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,792.20,,,percent of total billed charges,,,428.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 65X4MM,10388364,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,932.00,279.60,361.62,792.20,,,,,,,,,,,,,,,,,,,,361.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792.20,,,percent of total billed charges,,,419.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 65X4MM,10388364,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,932.00,279.60,396.10,792.20,,,,,,,,,,,,,service not payable,,,,,,,470.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,396.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,699.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,466.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,699.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,792.20,,,percent of total billed charges,,,428.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN PT 4X70MM X_14376-70 X_DEPUY,10388365,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN PT 4X70MM X_14376-70 X_DEPUY,10388365,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TUBULAR 3.5X61MM 5H,10388417,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,452.00,135.60,175.38,384.20,,,,,,,,,,,,,,,,,,,,175.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,339.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,226.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.20,,,percent of total billed charges,,,203.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TUBULAR 3.5X61MM 5H,10388417,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,452.00,135.60,192.10,384.20,,,,,,,,,,,,,service not payable,,,,,,,227.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,192.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,339.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,226.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,339.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,384.20,,,percent of total billed charges,,,207.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE TUBULAR 6H 3.5MM,10388418,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE TUBULAR 6H 3.5MM,10388418,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TUBULAR 7H 3.5MM X_14355-7 X_DEPUY,10388419,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TUBULAR 7H 3.5MM X_14355-7 X_DEPUY,10388419,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 36X4MM,10388456,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 36X4MM,10388456,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN CANC 38X4MM,10388457,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN CANC 38X4MM,10388457,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PT 4X40MM X_14376-40 X_DEPUY,10388458,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PT 4X40MM X_14376-40 X_DEPUY,10388458,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING KNEE INSERT 16X71-75MM,10388480,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3131.00,939.30,1214.83,2661.35,,,,,,,,,,,,,,,,,,,,1214.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1330.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2348.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2661.35,,,percent of total billed charges,,,1408.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE INSERT 16X71-75MM,10388480,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3131.00,939.30,1330.68,2661.35,,,,,,,,,,,,,service not payable,,,,,,,1579.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1330.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2348.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2348.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2661.35,,,percent of total billed charges,,,1440.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4HOLE STR REG 2.0MM,10388507,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4HOLE STR REG 2.0MM,10388507,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4HOLE STR LONG 1X2MM,10388508,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,478.00,143.40,185.46,406.30,,,,,,,,,,,,,,,,,,,,185.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,358.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,239.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,,215.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4HOLE STR LONG 1X2MM,10388508,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,478.00,143.40,203.15,406.30,,,,,,,,,,,,,service not payable,,,,,,,241.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,203.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,358.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,239.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,358.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,,219.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE M/G UNICOMP 48MM,10388549,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,536.00,160.80,207.97,455.60,,,,,,,,,,,,,,,,,,,,207.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.60,,,percent of total billed charges,,,241.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE M/G UNICOMP 48MM,10388549,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,536.00,160.80,227.80,455.60,,,,,,,,,,,,,service not payable,,,,,,,270.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,402.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,455.60,,,percent of total billed charges,,,246.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL GAMMA 3 RT 10X300MM 130D,10388551,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL GAMMA 3 RT 10X300MM 130D,10388551,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FIBULOCK 3.8X130MM L,10389166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FIBULOCK 3.8X130MM L,10389166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST T25 4.5X95MM,10389167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,171.00,51.30,66.35,145.35,,,,,,,,,,,,,,,,,,,,66.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,128.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.35,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST T25 4.5X95MM,10389167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,171.00,51.30,72.67,145.35,,,,,,,,,,,,,service not payable,,,,,,,86.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,72.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,128.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,85.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,128.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,145.35,,,percent of total billed charges,,,78.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT PTA 7X40MMX130CM,10389168,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 22.0,10389172,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 22.0,10389172,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 6X120,10389173,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,5820.00,1746.00,2258.16,4947.0,,2851.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2444.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2258.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2473.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4365.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2910.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4947.0,,,percent of total billed charges,,,2619.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 6X120,10389173,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,5820.00,1746.00,2444.40,4947.0,,2851.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2444.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2935.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2473.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4365.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2910.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4365.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4947.0,,,percent of total billed charges,,,2677.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 6X150,10389174,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,6310.00,1893.00,2448.28,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2448.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5363.5,,,percent of total billed charges,,,2839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 6X150,10389174,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,6310.00,1893.00,2650.20,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3182.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5363.5,,,percent of total billed charges,,,2902.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE PROGREAT 3F R130CM,10389176,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,1047.51,,,percent of total billed charges,,,,,,,,service not payable,827.16,,,percent of total billed charges,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,1101.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1101.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN TROC ANT 10MMX40CM,10389177,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11556.00,3466.80,4483.73,9822.60,,5662.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4853.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4483.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4911.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8667.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5778.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9822.60,,,percent of total billed charges,,,5200.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN TROC ANT 10MMX40CM,10389177,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11556.00,3466.80,4853.52,9822.60,,5662.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4853.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5828.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4911.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8667.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5778.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8667.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9822.60,,,percent of total billed charges,,,5315.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN TROC ANT 10MMX42CM,10389178,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,11556.00,3466.80,4483.73,9822.60,,5662.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4853.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4483.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4911.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8667.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5778.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9822.60,,,percent of total billed charges,,,5200.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN TROC ANT 10MMX42CM,10389178,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,11556.00,3466.80,4853.52,9822.60,,5662.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4853.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5828.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4911.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8667.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5778.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8667.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9822.60,,,percent of total billed charges,,,5315.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ3 5MM,10389198,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ3 5MM,10389198,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ3 6MM,10389199,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ3 6MM,10389199,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PS RP SZ4 12MM X_1516-50-412 X_DEPUY,10389204,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6361.00,1908.30,2468.07,5406.85,,3116.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2671.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2468.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2703.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4770.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5406.85,,,percent of total billed charges,,,2862.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PS RP SZ4 12MM X_1516-50-412 X_DEPUY,10389204,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6361.00,1908.30,2671.62,5406.85,,3116.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2671.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3208.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2703.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4770.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4770.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5406.85,,,percent of total billed charges,,,2926.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ4 5MM,10389209,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ4 5MM,10389209,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ4 8MM,10389210,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ4 8MM,10389210,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ5 12MM,10389211,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ5 12MM,10389211,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ6 10MM,10389214,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ6 10MM,10389214,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ6 12MM,10389215,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ6 12MM,10389215,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PS RP SZ6 14MM X_1516-50-614 X_DEPUY,10389216,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PS RP SZ6 14MM X_1516-50-614 X_DEPUY,10389216,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ7 10MM,10389220,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ7 10MM,10389220,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ7 14MM,10389222,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ7 14MM,10389222,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ8 12MM,10389225,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ8 12MM,10389225,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ8 8MM,10389231,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ8 8MM,10389231,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ9 10MM,10389232,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ9 10MM,10389232,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ9 5MM,10389238,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ9 5MM,10389238,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PS RP SZ9 7MM,10389240,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PS RP SZ9 7MM,10389240,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB RP CEM SZ10 X_1506-10-010 X_DEPUY,10389242,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4017.00,1205.10,1558.60,3414.45,,,,,,,,,,,,,,,,,,,,1558.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3414.45,,,percent of total billed charges,,,1807.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB RP CEM SZ10 X_1506-10-010 X_DEPUY,10389242,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4017.00,1205.10,1707.22,3414.45,,,,,,,,,,,,,service not payable,,,,,,,2026.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3414.45,,,percent of total billed charges,,,1847.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB RP CEM SZ9 X_1506-10-009 X_DEPUY,10389243,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4017.00,1205.10,1558.60,3414.45,,,,,,,,,,,,,,,,,,,,1558.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3414.45,,,percent of total billed charges,,,1807.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB RP CEM SZ9 X_1506-10-009 X_DEPUY,10389243,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4017.00,1205.10,1707.22,3414.45,,,,,,,,,,,,,service not payable,,,,,,,2026.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3414.45,,,percent of total billed charges,,,1847.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL HIP ACETABULAR 62MM,10389247,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL HIP ACETABULAR 62MM,10389247,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE BONE KIRSCHNER 0.062X4IN,10389248,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,79.00,23.70,30.65,67.15,,,,,,,,,,,,,,,,,,,,30.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,59.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.15,,,percent of total billed charges,,,35.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE BONE KIRSCHNER 0.062X4IN,10389248,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,79.00,23.70,33.57,67.15,,,,,,,,,,,,,service not payable,,,,,,,39.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,33.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,59.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,39.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,59.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,67.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE KIRSCHNER 0.035X4IN,10389252,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,113.00,33.90,43.84,96.05,,,,,,,,,,,,,,,,,,,,43.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,84.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.05,,,percent of total billed charges,,,50.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE KIRSCHNER 0.035X4IN,10389252,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,113.00,33.90,48.02,96.05,,,,,,,,,,,,,service not payable,,,,,,,57.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,48.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,84.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,56.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,84.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,96.05,,,percent of total billed charges,,,51.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Thyroid Stimulating Immunoglobulin (TSI),10389592,CDM,0300,RC,84445,CPT,,,,,,outpatient,facility,,,203.00,60.90,48.32,203.0,,203.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,49.84,,,fee schedule,,,161.24,,,fee schedule,,,106.07,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,105.28,,,fee schedule,,,48.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.84,,,fee schedule,,,114.94,,,fee schedule,,,,,,,,,49.84,,,fee schedule,,,,,,,,,65.30,,,fee schedule,,,103.75,,,fee schedule,,,152.25,,,percent of total billed charges,,,49.84,,,fee schedule,,,48.32,,,fee schedule,,,50.84,,,fee schedule,,,76.79,,,fee schedule,,,49.84,,,fee schedule,,,152.25,,,percent of total billed charges,,,,,,,,,50.84,,,fee schedule,,,,,,,,,172.55,,,percent of total billed charges,,,93.38,,,percent of total billed charges,,,,,,,,,55.95,,,fee schedule,,,49.84,,,fee schedule,,,,,,,,,49.33,,,fee schedule,,,49.84,,,fee schedule,,,,,,,,,50.34,,,fee schedule,,,,,,,,
Thyroid Stimulating Immunoglobulin (TSI),10389592,CDM,0300,RC,84445,CPT,399,EAPG,,,,outpatient,facility,,,203.00,60.90,41.30,150.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,128.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,41.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,41.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,82.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,90.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CORTEX 2.7X28MM X_202.888 X_DEPUY SYNTHES,10389655,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,305.00,91.50,118.34,259.25,,,,,,,,,,,,,,,,,,,,118.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.25,,,percent of total billed charges,,,137.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2.7X28MM X_202.888 X_DEPUY SYNTHES,10389655,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,305.00,91.50,129.62,259.25,,,,,,,,,,,,,service not payable,,,,,,,153.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,228.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,259.25,,,percent of total billed charges,,,140.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB LAT DIST 5H RT 99MM X_02.112.140 X_DEPUY,10389710,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2971.00,891.30,1152.75,2525.35,,,,,,,,,,,,,,,,,,,,1152.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1262.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2228.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1485.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2525.35,,,percent of total billed charges,,,1336.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB LAT DIST 5H RT 99MM X_02.112.140 X_DEPUY,10389710,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2971.00,891.30,1262.68,2525.35,,,,,,,,,,,,,service not payable,,,,,,,1498.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1262.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2228.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1485.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2228.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2525.35,,,percent of total billed charges,,,1366.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB LAT DIST 6H RT 112MM X_02.112.142 X_DEPU,10389712,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4021.00,1206.30,1560.15,3417.85,,,,,,,,,,,,,,,,,,,,1560.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1708.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3015.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2010.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3417.85,,,percent of total billed charges,,,1809.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB LAT DIST 6H RT 112MM X_02.112.142 X_DEPU,10389712,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4021.00,1206.30,1708.92,3417.85,,,,,,,,,,,,,service not payable,,,,,,,2028.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1708.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3015.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2010.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3015.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3417.85,,,percent of total billed charges,,,1849.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYNTHES TI TROCHANTERIC REATTACHMENT DEVICE W/CABL,10389796,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7694.00,2308.20,2985.27,6539.90,,3770.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3231.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2985.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3269.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5770.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3847.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6539.90,,,percent of total billed charges,,,3462.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYNTHES TI TROCHANTERIC REATTACHMENT DEVICE W/CABL,10389796,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7694.00,2308.20,3231.48,6539.90,,3770.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3231.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3880.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3269.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5770.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3847.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5770.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6539.90,,,percent of total billed charges,,,3539.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL CANN 12X375MM X_04.004.655S X_DEPUY SY,10389815,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5728.00,1718.40,2222.46,4868.80,,2806.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2405.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2222.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2434.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4296.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2864.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4868.80,,,percent of total billed charges,,,2577.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL CANN 12X375MM X_04.004.655S X_DEPUY SY,10389815,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5728.00,1718.40,2405.76,4868.80,,2806.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2405.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2889.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2434.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4296.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2864.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4296.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4868.80,,,percent of total billed charges,,,2634.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL CANN 8X405MM X_04.004.261S X_DEPUY SYN,10389823,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6262.00,1878.60,2429.66,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2429.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5322.70,,,percent of total billed charges,,,2817.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL CANN 8X405MM X_04.004.261S X_DEPUY SYN,10389823,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6262.00,1878.60,2630.04,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3158.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5322.70,,,percent of total billed charges,,,2880.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL CANN 8X420MM X_04.004.264S X_DEPUY SYN,10389824,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6262.00,1878.60,2429.66,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2429.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5322.70,,,percent of total billed charges,,,2817.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL CANN 8X420MM X_04.004.264S X_DEPUY SYN,10389824,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6262.00,1878.60,2630.04,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3158.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5322.70,,,percent of total billed charges,,,2880.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT WRIST LTHR MAL LT LG,10390413,CDM,0274,RC,L3908,HCPCS,,,,,,inpatient,facility,,,71.00,21.30,27.55,60.35,,,,,,,,,,,,,,,,,,,,27.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.35,,,percent of total billed charges,,,31.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST LTHR MAL LT LG,10390413,CDM,0274,RC,L3908,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,151.67,,,,,,,,66.04,,,fee schedule,,,,,,,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,138.92,,,fee schedule,,,46.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",67.36,,,fee schedule,,,151.67,,,fee schedule,,,,,,,,,66.04,,,fee schedule,,,,,,,,,30.18,,,percent of total billed charges,,Paid in addition to outpatient services ,136.90,,,fee schedule,,,53.25,,,percent of total billed charges,,,66.04,,,fee schedule,,,46.09,,,fee schedule,,,67.36,,,fee schedule,,,35.5,,,percent of total billed charges,,Paid in addition to outpatient services ,66.04,,,fee schedule,,,53.25,,,percent of total billed charges,,,46.09,,,fee schedule,,,67.36,,,fee schedule,,,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,,,,,,,66.04,,,fee schedule,,,,,,,,,,,,,,,66.04,,,fee schedule,,,,,,,,,66.70,,,fee schedule,,,,,,,,
STENT PERIPH120CM CATH5FR 6X40,10390463,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 6X40,10390463,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIPH120CM CATH5FR 6X60,10390464,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 6X60,10390464,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIPH120CM CATH5FR 6X80,10390465,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4746.00,1423.80,1841.45,4034.10,,,,,,,,,,,,,,,,,,,,1841.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2017.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3559.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2373.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4034.10,,,percent of total billed charges,,,2135.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 6X80,10390465,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4746.00,1423.80,2017.05,4034.10,,,,,,,,,,,,,service not payable,,,,,,,2393.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2017.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3559.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2373.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3559.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4034.10,,,percent of total billed charges,,,2183.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 6X100,10390466,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 6X100,10390466,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 6X20,10390467,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,6310.00,1893.00,2448.28,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2448.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5363.5,,,percent of total billed charges,,,2839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 6X20,10390467,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,6310.00,1893.00,2650.20,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3182.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5363.5,,,percent of total billed charges,,,2902.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIPH120CM CATH5FR 7X40,10390468,CDM,0278,RC,C1886,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 7X40,10390468,CDM,0278,RC,C1886,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIPH120CM CATH5FR 7X60,10390469,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4843.00,1452.90,1879.08,4116.55,,,,,,,,,,,,,,,,,,,,1879.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2058.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3632.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2421.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4116.55,,,percent of total billed charges,,,2179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 7X60,10390469,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4843.00,1452.90,2058.28,4116.55,,,,,,,,,,,,,service not payable,,,,,,,2442.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2058.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3632.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2421.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3632.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4116.55,,,percent of total billed charges,,,2227.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 7X100,10390471,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 7X100,10390471,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 7X120,10390472,CDM,0278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,3393.00,1017.90,1316.48,2884.05,,,,,,,,,,,,,,,,,,,,1316.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2884.05,,,percent of total billed charges,,,1526.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 7X120,10390472,CDM,0278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,3393.00,1017.90,1442.02,2884.05,,,,,,,,,,,,,service not payable,,,,,,,1711.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1442.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2544.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2544.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2884.05,,,percent of total billed charges,,,1560.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 7X150,10390473,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3360.00,1008.00,1303.68,2856.0,,,,,,,,,,,,,,,,,,,,1303.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2520.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2856.0,,,percent of total billed charges,,,1512.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 7X150,10390473,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3360.00,1008.00,1428.0,2856.0,,,,,,,,,,,,,service not payable,,,,,,,1694.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2520.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2520.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2856.0,,,percent of total billed charges,,,1545.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 7X20,10390474,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,6310.00,1893.00,2448.28,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2448.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5363.5,,,percent of total billed charges,,,2839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 7X20,10390474,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,6310.00,1893.00,2650.20,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3182.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5363.5,,,percent of total billed charges,,,2902.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIPH120CM CATH5FR 8X80,10390475,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIPH120CM CATH5FR 8X80,10390475,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 8X100,10390476,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 8X100,10390476,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 7X37MM 135CM,10390486,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 7X37MM 135CM,10390486,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 8X27MM 135CM,10390487,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 8X27MM 135CM,10390487,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 8X37MM 135CM,10390488,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 8X37MM 135CM,10390488,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 9X37MM 135CM,10390489,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 9X37MM 135CM,10390489,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 10X27MM 135CM,10390490,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 10X27MM 135CM,10390490,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN COVERED 9MMX5CM,10390501,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10792.00,3237.60,4187.30,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4187.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9173.20,,,percent of total billed charges,,,4856.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN COVERED 9MMX5CM,10390501,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10792.00,3237.60,4532.64,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5443.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9173.20,,,percent of total billed charges,,,4964.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN COVERED 9MMX10CM,10390502,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN COVERED 9MMX10CM,10390502,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Helicobacter pylori Stool Antigen - FH,10390788,CDM,0300,RC,87338,CPT,,,,,,outpatient,facility,,,199.00,59.70,13.66,169.15,,61.11,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.09,,,fee schedule,,,45.60,,,fee schedule,,,29.99,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,29.77,,,fee schedule,,,13.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.37,,,fee schedule,,,32.5,,,fee schedule,,,,,,,,,14.09,,,fee schedule,,,,,,,,,18.53,,,fee schedule,,,29.34,,,fee schedule,,,149.25,,,percent of total billed charges,,,14.09,,,fee schedule,,,13.66,,,fee schedule,,,14.37,,,fee schedule,,,21.80,,,fee schedule,,,14.09,,,fee schedule,,,149.25,,,percent of total billed charges,,,,,,,,,14.37,,,fee schedule,,,,,,,,,169.15,,,percent of total billed charges,,,91.54,,,percent of total billed charges,,,,,,,,,15.82,,,fee schedule,,,14.09,,,fee schedule,,,,,,,,,13.95,,,fee schedule,,,14.09,,,fee schedule,,,,,,,,,14.23,,,fee schedule,,,,,,,,
Helicobacter pylori Stool Antigen - FH,10390788,CDM,0300,RC,87338,CPT,396,EAPG,,,,outpatient,facility,,,199.00,59.70,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SEALANT TISSEEL VH S/D 4 ML X_1504515 X_BAXTER HEA,10390925,CDM,0623,RC,A6250,HCPCS,,,,,,outpatient,facility,,,1459.00,437.70,620.08,1240.15,,901.66,,,percent of total billed charges,,,,,,,,service not payable,711.99,,,percent of total billed charges,,,735.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,620.08,,,percent of total billed charges,,,,,,,,,1094.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,729.5,,,percent of total billed charges,,,,,,,,service not payable,1094.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1240.15,,,percent of total billed charges,,,671.14,,,percent of total billed charges,,,,,,,,,948.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,948.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PT 97110 Therapeutic Procedure/Exercise,10391138,CDM,0420,RC,97110,CPT,,,,,GP  ,outpatient,facility,,,195.00,58.50,24.88,260.0,,96.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,26.96,,,fee schedule,,,71.74,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,56.72,,,fee schedule,,,24.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",27.51,,,fee schedule,,,61.95,,,fee schedule,,,,,,,,,26.97,,,fee schedule,,,,,,,,,173.0,,,per diem,,,55.90,,,fee schedule,,,146.25,,,percent of total billed charges,,,26.96,,,fee schedule,,,24.88,,,fee schedule,,,27.5,,,fee schedule,,,204.0,,,per diem,,,26.97,,,fee schedule,,,146.25,,,percent of total billed charges,,,24.88,,,fee schedule,,,27.5,,,fee schedule,,,,,,,,,165.75,,,percent of total billed charges,,,89.70,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,26.97,,,fee schedule,,,,,,,,,229.0,,,per diem,,,26.96,,,fee schedule,,,,,,,,,26.96,,,fee schedule,,,,,,,,
PT 97110 Therapeutic Procedure/Exercise,10391138,CDM,0420,RC,97110,CPT,269,EAPG,,,GP  ,outpatient,facility,,,195.00,58.50,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97162 EVAL MOD CMPLX,10391146,CDM,0424,RC,97162,CPT,,,,,GP  ,outpatient,facility,,,286.00,85.80,73.33,260.0,,176.75,,,percent of total billed charges,,,91.74,,,fee schedule,,,140.71,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,192.99,,,fee schedule,,,73.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",93.56,,,fee schedule,,,210.68,,,fee schedule,,,,,,,,,91.73,,,fee schedule,,,,,,,,,173.0,,,per diem,,,190.19,,,fee schedule,,,214.5,,,percent of total billed charges,,,91.74,,,fee schedule,,,73.33,,,fee schedule,,,93.57,,,fee schedule,,,204.0,,,per diem,,,91.73,,,fee schedule,,,214.5,,,percent of total billed charges,,,73.33,,,fee schedule,,,93.57,,,fee schedule,,,,,,,,,243.10,,,percent of total billed charges,,,131.56,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,91.73,,,fee schedule,,,,,,,,,229.0,,,per diem,,,91.74,,,fee schedule,,,,,,,,,91.74,,,fee schedule,,,,,,,,
PT 97162 EVAL MOD CMPLX,10391146,CDM,0424,RC,97162,CPT,271,EAPG,,,GP  ,outpatient,facility,,,286.00,85.80,165.39,328.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,279.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,187.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,206.65,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97530 Therapeutic Activity Units,10391150,CDM,0420,RC,97530,CPT,,,,,GP  ,outpatient,facility,,,173.00,51.90,30.83,260.0,,103.76,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,32.17,,,fee schedule,,,77.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,67.67,,,fee schedule,,,30.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",32.84,,,fee schedule,,,73.95,,,fee schedule,,,,,,,,,32.20,,,fee schedule,,,,,,,,,173.0,,,per diem,,,66.69,,,fee schedule,,,129.75,,,percent of total billed charges,,,32.17,,,fee schedule,,,30.83,,,fee schedule,,,32.81,,,fee schedule,,,204.0,,,per diem,,,32.20,,,fee schedule,,,129.75,,,percent of total billed charges,,,30.83,,,fee schedule,,,32.81,,,fee schedule,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,32.20,,,fee schedule,,,,,,,,,229.0,,,per diem,,,32.17,,,fee schedule,,,,,,,,,32.17,,,fee schedule,,,,,,,,
PT 97530 Therapeutic Activity Units,10391150,CDM,0420,RC,97530,CPT,269,EAPG,,,GP  ,outpatient,facility,,,173.00,51.90,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97163 EVAL HIGH CMPLX,10391154,CDM,0424,RC,97163,CPT,,,,,GP  ,outpatient,facility,,,286.00,85.80,73.33,260.0,,176.75,,,percent of total billed charges,,,91.74,,,fee schedule,,,140.71,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,192.99,,,fee schedule,,,73.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",93.56,,,fee schedule,,,210.68,,,fee schedule,,,,,,,,,91.73,,,fee schedule,,,,,,,,,173.0,,,per diem,,,190.19,,,fee schedule,,,214.5,,,percent of total billed charges,,,91.74,,,fee schedule,,,73.33,,,fee schedule,,,93.57,,,fee schedule,,,204.0,,,per diem,,,91.73,,,fee schedule,,,214.5,,,percent of total billed charges,,,73.33,,,fee schedule,,,93.57,,,fee schedule,,,,,,,,,243.10,,,percent of total billed charges,,,131.56,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,91.73,,,fee schedule,,,,,,,,,229.0,,,per diem,,,91.74,,,fee schedule,,,,,,,,,91.74,,,fee schedule,,,,,,,,
PT 97163 EVAL HIGH CMPLX,10391154,CDM,0424,RC,97163,CPT,271,EAPG,,,GP  ,outpatient,facility,,,286.00,85.80,165.39,328.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,279.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,187.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,206.65,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97116 Gait Training Units,10391158,CDM,0420,RC,97116,CPT,,,,,GP  ,outpatient,facility,,,140.00,42.00,21.57,260.0,,85.03,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,26.96,,,fee schedule,,,63.45,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,56.72,,,fee schedule,,,21.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",27.51,,,fee schedule,,,61.95,,,fee schedule,,,,,,,,,26.97,,,fee schedule,,,,,,,,,173.0,,,per diem,,,55.90,,,fee schedule,,,105.0,,,percent of total billed charges,,,26.96,,,fee schedule,,,21.57,,,fee schedule,,,27.5,,,fee schedule,,,204.0,,,per diem,,,26.97,,,fee schedule,,,105.0,,,percent of total billed charges,,,21.57,,,fee schedule,,,27.5,,,fee schedule,,,,,,,,,119.0,,,percent of total billed charges,,,64.40,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,26.97,,,fee schedule,,,,,,,,,229.0,,,per diem,,,26.96,,,fee schedule,,,,,,,,,26.96,,,fee schedule,,,,,,,,
PT 97116 Gait Training Units,10391158,CDM,0420,RC,97116,CPT,493,EAPG,,,GP  ,outpatient,facility,,,140.00,42.00,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97164 REEVAL TIME,10391162,CDM,0424,RC,97164,CPT,,,,,GP  ,outpatient,facility,,,385.00,115.50,49.61,327.25,,237.93,,,percent of total billed charges,,,63.10,,,fee schedule,,,189.42,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,132.75,,,fee schedule,,,49.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",64.40,,,fee schedule,,,145.02,,,fee schedule,,,,,,,,,63.14,,,fee schedule,,,,,,,,,173.0,,,per diem,,,130.83,,,fee schedule,,,288.75,,,percent of total billed charges,,,63.10,,,fee schedule,,,49.61,,,fee schedule,,,64.36,,,fee schedule,,,204.0,,,per diem,,,63.14,,,fee schedule,,,288.75,,,percent of total billed charges,,,49.61,,,fee schedule,,,64.36,,,fee schedule,,,,,,,,,327.25,,,percent of total billed charges,,,177.10,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,63.14,,,fee schedule,,,,,,,,,229.0,,,per diem,,,63.10,,,fee schedule,,,,,,,,,63.10,,,fee schedule,,,,,,,,
PT 97164 REEVAL TIME,10391162,CDM,0424,RC,97164,CPT,271,EAPG,,,GP  ,outpatient,facility,,,385.00,115.50,165.39,328.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,279.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,187.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,206.65,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97140 Manual Therapy Technique Units,10391166,CDM,0420,RC,97140,CPT,,,,,GP  ,outpatient,facility,,,155.00,46.50,23.28,260.0,,89.40,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,25.46,,,fee schedule,,,66.71,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,53.55,,,fee schedule,,,23.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",25.97,,,fee schedule,,,58.47,,,fee schedule,,,,,,,,,25.46,,,fee schedule,,,,,,,,,173.0,,,per diem,,,52.77,,,fee schedule,,,116.25,,,percent of total billed charges,,,25.46,,,fee schedule,,,23.28,,,fee schedule,,,25.97,,,fee schedule,,,204.0,,,per diem,,,25.46,,,fee schedule,,,116.25,,,percent of total billed charges,,,23.28,,,fee schedule,,,25.97,,,fee schedule,,,,,,,,,131.75,,,percent of total billed charges,,,71.30,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,25.46,,,fee schedule,,,,,,,,,229.0,,,per diem,,,25.46,,,fee schedule,,,,,,,,,25.46,,,fee schedule,,,,,,,,
PT 97140 Manual Therapy Technique Units,10391166,CDM,0420,RC,97140,CPT,269,EAPG,,,GP  ,outpatient,facility,,,155.00,46.50,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 99211 EM Level 1,10391170,CDM,0510,RC,99211,CPT,,,,,,outpatient,facility,,,450.00,135.00,11.49,382.5,,278.10,,,percent of total billed charges,,,,,,,,service not payable,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.49,,,fee schedule,,,,,,,,service not payable,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PT 99211 EM Level 1,10391170,CDM,0510,RC,99211,CPT,852,EAPG,,,,outpatient,facility,,,450.00,135.00,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 99211 EM Level 1,10391170,CDM,0510,RC,G0463,HCPCS,,,,,,outpatient,facility,,,450.00,135.00,207.0,382.5,,278.10,,,percent of total billed charges,,,,,,,,,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
PT 99211 EM Level 1,10391170,CDM,0510,RC,G0463,HCPCS,05012,APC,,,,outpatient,facility,,,450.00,135.00,118.54,283.83,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,259.97,,,fee schedule,,,118.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.05,,,fee schedule,,,283.83,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,256.20,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,118.54,,,fee schedule,,,126.05,,,fee schedule,,,,,,,,,123.58,,,fee schedule,,,,,,,,,118.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,,,,,,,123.58,,,fee schedule,,,,,,,,,124.82,,,fee schedule,,,,,,,,
PT 99211 EM Level 1,10391170,CDM,0510,RC,G0463,HCPCS,852,EAPG,,,,outpatient,facility,,,450.00,135.00,46.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97113 Aquatic Therapy Units,10391174,CDM,0420,RC,97113,CPT,,,,,GP  ,outpatient,facility,,,173.00,51.90,27.13,260.0,,127.21,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.02,,,fee schedule,,,94.92,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,71.56,,,fee schedule,,,27.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",34.74,,,fee schedule,,,78.22,,,fee schedule,,,,,,,,,34.06,,,fee schedule,,,,,,,,,173.0,,,per diem,,,70.52,,,fee schedule,,,129.75,,,percent of total billed charges,,,34.02,,,fee schedule,,,27.13,,,fee schedule,,,34.70,,,fee schedule,,,204.0,,,per diem,,,34.06,,,fee schedule,,,129.75,,,percent of total billed charges,,,27.13,,,fee schedule,,,34.70,,,fee schedule,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,34.06,,,fee schedule,,,,,,,,,229.0,,,per diem,,,34.02,,,fee schedule,,,,,,,,,34.02,,,fee schedule,,,,,,,,
PT 97113 Aquatic Therapy Units,10391174,CDM,0420,RC,97113,CPT,269,EAPG,,,GP  ,outpatient,facility,,,173.00,51.90,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97010 Hot Pack/Cold Pack,10391178,CDM,0420,RC,97010,CPT,,,,,GP  ,outpatient,facility,,,118.00,35.40,9.42,260.0,,17.33,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,12.93,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,9.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,173.0,,,per diem,,,,,,,,,88.5,,,percent of total billed charges,,,,,,,,service not payable,9.42,,,fee schedule,,,,,,,,,204.0,,,per diem,,,,,,,,service not payable,88.5,,,percent of total billed charges,,,9.42,,,fee schedule,,,,,,,,service not payable,,,,,,,100.3,,,percent of total billed charges,,,54.28,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,service not payable,,,,,,,229.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PT 97010 Hot Pack/Cold Pack,10391178,CDM,0420,RC,97010,CPT,493,EAPG,,,GP  ,outpatient,facility,,,118.00,35.40,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97112 Neuromuscular Reeducation Units,10391182,CDM,0420,RC,97112,CPT,,,,,GP  ,outpatient,facility,,,160.00,48.00,25.96,260.0,,99.80,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,30.01,,,fee schedule,,,74.47,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,63.13,,,fee schedule,,,25.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.62,,,fee schedule,,,68.95,,,fee schedule,,,,,,,,,30.02,,,fee schedule,,,,,,,,,173.0,,,per diem,,,62.22,,,fee schedule,,,120.0,,,percent of total billed charges,,,30.01,,,fee schedule,,,25.96,,,fee schedule,,,30.61,,,fee schedule,,,204.0,,,per diem,,,30.02,,,fee schedule,,,120.0,,,percent of total billed charges,,,25.96,,,fee schedule,,,30.61,,,fee schedule,,,,,,,,,136.0,,,percent of total billed charges,,,73.60,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,30.02,,,fee schedule,,,,,,,,,229.0,,,per diem,,,30.01,,,fee schedule,,,,,,,,,30.01,,,fee schedule,,,,,,,,
PT 97112 Neuromuscular Reeducation Units,10391182,CDM,0420,RC,97112,CPT,269,EAPG,,,GP  ,outpatient,facility,,,160.00,48.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97014 Electrical Stimulation Unattend,10391186,CDM,0510,RC,G0283,HCPCS,,,,,,outpatient,facility,,,560.00,168.00,11.37,476.0,,346.08,,,percent of total billed charges,,,11.39,,,fee schedule,,,273.28,,,percent of total billed charges,,,282.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,23.97,,,fee schedule,,,12.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.6,,,fee schedule,,,26.13,,,fee schedule,,,,,,,,,11.37,,,fee schedule,,,,,,,,,,,,,,service not payable,23.62,,,fee schedule,,,420.0,,,percent of total billed charges,,,11.39,,,fee schedule,,,12.05,,,fee schedule,,,11.62,,,fee schedule,,,,,,,,service not payable,11.37,,,fee schedule,,,,,,,,service not payable,12.05,,,fee schedule,,,11.62,,,fee schedule,,,,,,,,,476.0,,,percent of total billed charges,,,257.60,,,percent of total billed charges,,,,,,,,,364.0,,,percent of total billed charges,,,11.37,,,fee schedule,,,,,,,,,364.0,,,percent of total billed charges,,,11.39,,,fee schedule,,,,,,,,,11.39,,,fee schedule,,,,,,,,
PT 97014 Electrical Stimulation Unattend,10391186,CDM,0510,RC,G0283,HCPCS,493,EAPG,,,,outpatient,facility,,,560.00,168.00,72.54,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97014 Electrical Stimulation Unattend,10391186,CDM,0420,RC,97014,CPT,,,,,GP  ,outpatient,facility,,,90.00,27.00,12.83,260.0,,47.09,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,35.14,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,45.0,,,fee schedule,,,12.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,45.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,173.0,,,per diem,,,,,,,,,67.5,,,percent of total billed charges,,,,,,,,service not payable,12.83,,,fee schedule,,,,,,,,,204.0,,,per diem,,,,,,,,service not payable,67.5,,,percent of total billed charges,,,12.83,,,fee schedule,,,40.5,,,fee schedule,,,,,,,,,76.5,,,percent of total billed charges,,,41.40,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,service not payable,,,,,,,229.0,,,per diem,,,45.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PT 97014 Electrical Stimulation Unattend,10391186,CDM,0420,RC,97014,CPT,493,EAPG,,,GP  ,outpatient,facility,,,90.00,27.00,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97033 Iontophoresis Units,10391190,CDM,0420,RC,97033,CPT,,,,,GP  ,outpatient,facility,,,149.00,44.70,13.63,260.0,,95.80,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,17.43,,,fee schedule,,,71.48,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,36.66,,,fee schedule,,,13.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17.77,,,fee schedule,,,40.0,,,fee schedule,,,,,,,,,17.42,,,fee schedule,,,,,,,,,173.0,,,per diem,,,36.13,,,fee schedule,,,111.75,,,percent of total billed charges,,,17.43,,,fee schedule,,,13.63,,,fee schedule,,,17.78,,,fee schedule,,,204.0,,,per diem,,,17.42,,,fee schedule,,,111.75,,,percent of total billed charges,,,13.63,,,fee schedule,,,17.78,,,fee schedule,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,17.42,,,fee schedule,,,,,,,,,229.0,,,per diem,,,17.43,,,fee schedule,,,,,,,,,17.43,,,fee schedule,,,,,,,,
PT 97033 Iontophoresis Units,10391190,CDM,0420,RC,97033,CPT,493,EAPG,,,GP  ,outpatient,facility,,,149.00,44.70,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97012 Traction Mechanical,10391194,CDM,0420,RC,97012,CPT,,,,,GP  ,outpatient,facility,,,132.00,39.60,12.72,260.0,,47.81,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.33,,,fee schedule,,,35.67,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.05,,,fee schedule,,,12.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.57,,,fee schedule,,,30.56,,,fee schedule,,,,,,,,,13.30,,,fee schedule,,,,,,,,,173.0,,,per diem,,,27.64,,,fee schedule,,,99.0,,,percent of total billed charges,,,13.33,,,fee schedule,,,12.72,,,fee schedule,,,13.6,,,fee schedule,,,204.0,,,per diem,,,13.30,,,fee schedule,,,99.0,,,percent of total billed charges,,,12.72,,,fee schedule,,,13.6,,,fee schedule,,,,,,,,,112.2,,,percent of total billed charges,,,60.72,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,13.30,,,fee schedule,,,,,,,,,229.0,,,per diem,,,13.33,,,fee schedule,,,,,,,,,13.33,,,fee schedule,,,,,,,,
PT 97012 Traction Mechanical,10391194,CDM,0420,RC,97012,CPT,493,EAPG,,,GP  ,outpatient,facility,,,132.00,39.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97035 Ultrasound Units,10391198,CDM,0420,RC,97035,CPT,,,,,GP  ,outpatient,facility,,,195.00,58.50,10.32,260.0,,38.22,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.93,,,fee schedule,,,28.52,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.20,,,fee schedule,,,10.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.17,,,fee schedule,,,29.65,,,fee schedule,,,,,,,,,12.91,,,fee schedule,,,,,,,,,173.0,,,per diem,,,26.81,,,fee schedule,,,146.25,,,percent of total billed charges,,,12.93,,,fee schedule,,,10.32,,,fee schedule,,,13.19,,,fee schedule,,,204.0,,,per diem,,,12.91,,,fee schedule,,,146.25,,,percent of total billed charges,,,10.32,,,fee schedule,,,13.19,,,fee schedule,,,,,,,,,165.75,,,percent of total billed charges,,,89.70,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,12.91,,,fee schedule,,,,,,,,,229.0,,,per diem,,,12.93,,,fee schedule,,,,,,,,,12.93,,,fee schedule,,,,,,,,
PT 97035 Ultrasound Units,10391198,CDM,0420,RC,97035,CPT,493,EAPG,,,GP  ,outpatient,facility,,,195.00,58.50,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97032 Electrical Stimulation Attended,10391206,CDM,0420,RC,97032,CPT,,,,,GP  ,outpatient,facility,,,135.00,40.50,13.30,260.0,,56.99,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.33,,,fee schedule,,,42.52,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.05,,,fee schedule,,,15.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.57,,,fee schedule,,,30.56,,,fee schedule,,,,,,,,,13.30,,,fee schedule,,,,,,,,,173.0,,,per diem,,,27.64,,,fee schedule,,,101.25,,,percent of total billed charges,,,13.33,,,fee schedule,,,15.99,,,fee schedule,,,13.6,,,fee schedule,,,204.0,,,per diem,,,13.30,,,fee schedule,,,101.25,,,percent of total billed charges,,,15.99,,,fee schedule,,,13.6,,,fee schedule,,,,,,,,,114.75,,,percent of total billed charges,,,62.10,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,13.30,,,fee schedule,,,,,,,,,229.0,,,per diem,,,13.33,,,fee schedule,,,,,,,,,13.33,,,fee schedule,,,,,,,,
PT 97032 Electrical Stimulation Attended,10391206,CDM,0420,RC,97032,CPT,493,EAPG,,,GP  ,outpatient,facility,,,135.00,40.50,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 29540 Strapping Ankle/Foot,10391210,CDM,0420,RC,29540,CPT,,,,,GP  ,outpatient,facility,,,155.00,46.50,71.30,260.0,,95.79,,,percent of total billed charges,,,,,,,,,75.64,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,116.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,116.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.75,,,percent of total billed charges,,,71.30,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PT 29540 Strapping Ankle/Foot,10391210,CDM,0420,RC,29540,CPT,05101,APC,,,GP  ,outpatient,facility,,,155.00,46.50,145.14,347.54,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,318.32,,,fee schedule,,,145.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",154.35,,,fee schedule,,,347.54,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,313.71,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,145.14,,,fee schedule,,,154.35,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,145.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",154.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,152.83,,,fee schedule,,,,,,,,
PT 29540 Strapping Ankle/Foot,10391210,CDM,0420,RC,29540,CPT,40,EAPG,,,GP  ,outpatient,facility,,,155.00,46.50,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97034 Contrast Bath Units,10391214,CDM,0420,RC,97034,CPT,,,,,GP  ,outpatient,facility,,,115.00,34.50,12.28,260.0,,53.52,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.64,,,fee schedule,,,39.94,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.60,,,fee schedule,,,12.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.86,,,fee schedule,,,28.97,,,fee schedule,,,,,,,,,12.61,,,fee schedule,,,,,,,,,173.0,,,per diem,,,26.21,,,fee schedule,,,86.25,,,percent of total billed charges,,,12.64,,,fee schedule,,,12.28,,,fee schedule,,,12.89,,,fee schedule,,,204.0,,,per diem,,,12.61,,,fee schedule,,,86.25,,,percent of total billed charges,,,12.28,,,fee schedule,,,12.89,,,fee schedule,,,,,,,,,97.75,,,percent of total billed charges,,,52.90,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,12.61,,,fee schedule,,,,,,,,,229.0,,,per diem,,,12.64,,,fee schedule,,,,,,,,,12.64,,,fee schedule,,,,,,,,
PT 97034 Contrast Bath Units,10391214,CDM,0420,RC,97034,CPT,493,EAPG,,,GP  ,outpatient,facility,,,115.00,34.50,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 29530 Strapping Knee,10391218,CDM,0420,RC,29530,CPT,,,,,GP  ,outpatient,facility,,,168.00,50.40,77.28,260.0,,103.82,,,percent of total billed charges,,,,,,,,,81.98,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.80,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PT 29530 Strapping Knee,10391218,CDM,0420,RC,29530,CPT,05734,APC,,,GP  ,outpatient,facility,,,168.00,50.40,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
PT 29530 Strapping Knee,10391218,CDM,0420,RC,29530,CPT,40,EAPG,,,GP  ,outpatient,facility,,,168.00,50.40,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97124 Massage Units,10391222,CDM,0420,RC,97124,CPT,,,,,GP  ,outpatient,facility,,,82.00,24.60,19.56,260.0,,78.81,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,27.56,,,fee schedule,,,58.81,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,57.98,,,fee schedule,,,19.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",28.13,,,fee schedule,,,63.35,,,fee schedule,,,,,,,,,27.58,,,fee schedule,,,,,,,,,173.0,,,per diem,,,57.14,,,fee schedule,,,61.5,,,percent of total billed charges,,,27.56,,,fee schedule,,,19.56,,,fee schedule,,,28.11,,,fee schedule,,,204.0,,,per diem,,,27.58,,,fee schedule,,,61.5,,,percent of total billed charges,,,19.56,,,fee schedule,,,28.11,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,27.58,,,fee schedule,,,,,,,,,229.0,,,per diem,,,27.56,,,fee schedule,,,,,,,,,27.56,,,fee schedule,,,,,,,,
PT 97124 Massage Units,10391222,CDM,0420,RC,97124,CPT,493,EAPG,,,GP  ,outpatient,facility,,,82.00,24.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 29240 Strapping Shoulder,10391226,CDM,0420,RC,29240,CPT,,,,,GP  ,outpatient,facility,,,235.00,70.50,108.10,260.0,,145.23,,,percent of total billed charges,,,,,,,,,114.68,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,176.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,176.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.75,,,percent of total billed charges,,,108.10,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PT 29240 Strapping Shoulder,10391226,CDM,0420,RC,29240,CPT,05734,APC,,,GP  ,outpatient,facility,,,235.00,70.50,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
PT 29240 Strapping Shoulder,10391226,CDM,0420,RC,29240,CPT,40,EAPG,,,GP  ,outpatient,facility,,,235.00,70.50,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97760 Orthotic Management/Training,10391230,CDM,0420,RC,97760,CPT,,,,,GP  ,outpatient,facility,,,170.00,51.00,26.81,260.0,,105.06,,,percent of total billed charges,,,42.51,,,fee schedule,,,82.96,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,89.42,,,fee schedule,,,26.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",43.42,,,fee schedule,,,97.77,,,fee schedule,,,,,,,,,42.57,,,fee schedule,,,,,,,,,173.0,,,per diem,,,88.13,,,fee schedule,,,127.5,,,percent of total billed charges,,,42.51,,,fee schedule,,,26.81,,,fee schedule,,,43.36,,,fee schedule,,,204.0,,,per diem,,,42.57,,,fee schedule,,,127.5,,,percent of total billed charges,,,26.81,,,fee schedule,,,43.36,,,fee schedule,,,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,42.57,,,fee schedule,,,,,,,,,229.0,,,per diem,,,42.51,,,fee schedule,,,,,,,,,42.51,,,fee schedule,,,,,,,,
PT 97760 Orthotic Management/Training,10391230,CDM,0420,RC,97760,CPT,269,EAPG,,,GP  ,outpatient,facility,,,170.00,51.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 90901 Biofeedback Training,10391234,CDM,0420,RC,90901,CPT,,,,,GP  ,outpatient,facility,,,189.00,56.70,36.30,260.0,,116.8,,,percent of total billed charges,,,36.30,,,fee schedule,,,92.23,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,76.36,,,fee schedule,,,,,,,,service not payable,37.03,,,fee schedule,,,83.37,,,fee schedule,,,,,,,,,36.30,,,fee schedule,,,,,,,,,173.0,,,per diem,,,75.26,,,fee schedule,,,141.75,,,percent of total billed charges,,,36.30,,,fee schedule,,,,,,,,service not payable,37.03,,,fee schedule,,,204.0,,,per diem,,,36.30,,,fee schedule,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,37.03,,,fee schedule,,,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,36.30,,,fee schedule,,,,,,,,,229.0,,,per diem,,,36.30,,,fee schedule,,,,,,,,,36.30,,,fee schedule,,,,,,,,
PT 90901 Biofeedback Training,10391234,CDM,0420,RC,90901,CPT,427,EAPG,,,GP  ,outpatient,facility,,,189.00,56.70,128.18,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97763 Subsequent Ortho Mgmt/Training,10391238,CDM,0420,RC,97763,CPT,,,,,GP  ,outpatient,facility,,,137.00,41.10,43.61,260.0,,84.67,,,percent of total billed charges,,,46.23,,,fee schedule,,,67.40,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,97.25,,,fee schedule,,,43.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",47.25,,,fee schedule,,,106.38,,,fee schedule,,,,,,,,,46.32,,,fee schedule,,,,,,,,,173.0,,,per diem,,,95.84,,,fee schedule,,,102.75,,,percent of total billed charges,,,46.23,,,fee schedule,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,204.0,,,per diem,,,46.32,,,fee schedule,,,102.75,,,percent of total billed charges,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,46.32,,,fee schedule,,,,,,,,,229.0,,,per diem,,,46.23,,,fee schedule,,,,,,,,,46.23,,,fee schedule,,,,,,,,
PT 97763 Subsequent Ortho Mgmt/Training,10391238,CDM,0420,RC,97763,CPT,269,EAPG,,,GP  ,outpatient,facility,,,137.00,41.10,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97750 Phys Performance Test/Measure,10391246,CDM,0420,RC,97750,CPT,,,,,GP  ,outpatient,facility,,,148.00,44.40,24.32,260.0,,91.46,,,percent of total billed charges,,,31.04,,,fee schedule,,,72.22,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,65.29,,,fee schedule,,,24.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",31.67,,,fee schedule,,,71.33,,,fee schedule,,,,,,,,,31.05,,,fee schedule,,,,,,,,,173.0,,,per diem,,,64.34,,,fee schedule,,,111.0,,,percent of total billed charges,,,31.04,,,fee schedule,,,24.32,,,fee schedule,,,31.66,,,fee schedule,,,204.0,,,per diem,,,31.05,,,fee schedule,,,111.0,,,percent of total billed charges,,,24.32,,,fee schedule,,,31.66,,,fee schedule,,,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,31.05,,,fee schedule,,,,,,,,,229.0,,,per diem,,,31.04,,,fee schedule,,,,,,,,,31.04,,,fee schedule,,,,,,,,
PT 97750 Phys Performance Test/Measure,10391246,CDM,0420,RC,97750,CPT,269,EAPG,,,GP  ,outpatient,facility,,,148.00,44.40,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97535 Self Care/Home Mgmt Training,10391254,CDM,0420,RC,97535,CPT,,,,,GP  ,outpatient,facility,,,152.00,45.60,27.91,260.0,,103.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,29.87,,,fee schedule,,,77.52,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,62.85,,,fee schedule,,,27.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.48,,,fee schedule,,,68.64,,,fee schedule,,,,,,,,,29.88,,,fee schedule,,,,,,,,,173.0,,,per diem,,,61.93,,,fee schedule,,,114.0,,,percent of total billed charges,,,29.87,,,fee schedule,,,27.91,,,fee schedule,,,30.47,,,fee schedule,,,204.0,,,per diem,,,29.88,,,fee schedule,,,114.0,,,percent of total billed charges,,,27.91,,,fee schedule,,,30.47,,,fee schedule,,,,,,,,,129.20,,,percent of total billed charges,,,69.92,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.88,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.87,,,fee schedule,,,,,,,,,29.87,,,fee schedule,,,,,,,,
PT 97535 Self Care/Home Mgmt Training,10391254,CDM,0420,RC,97535,CPT,493,EAPG,,,GP  ,outpatient,facility,,,152.00,45.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97150 Group Therapy Units,10391262,CDM,0420,RC,97150,CPT,,,,,GP  ,outpatient,facility,,,126.00,37.80,16.33,260.0,,52.30,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.35,,,fee schedule,,,39.03,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,34.40,,,fee schedule,,,16.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.66,,,fee schedule,,,37.52,,,fee schedule,,,,,,,,,16.33,,,fee schedule,,,,,,,,,173.0,,,per diem,,,33.90,,,fee schedule,,,94.5,,,percent of total billed charges,,,16.35,,,fee schedule,,,16.60,,,fee schedule,,,16.68,,,fee schedule,,,204.0,,,per diem,,,16.33,,,fee schedule,,,94.5,,,percent of total billed charges,,,16.60,,,fee schedule,,,16.68,,,fee schedule,,,,,,,,,107.10,,,percent of total billed charges,,,57.96,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,16.33,,,fee schedule,,,,,,,,,229.0,,,per diem,,,16.35,,,fee schedule,,,,,,,,,16.35,,,fee schedule,,,,,,,,
PT 97150 Group Therapy Units,10391262,CDM,0420,RC,97150,CPT,269,EAPG,,,GP  ,outpatient,facility,,,126.00,37.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97016 Vasopneumatic Device,10391266,CDM,0420,RC,97016,CPT,,,,,GP  ,outpatient,facility,,,87.00,26.10,10.78,260.0,,56.27,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.81,,,fee schedule,,,41.99,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,22.75,,,fee schedule,,,11.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.0,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,10.78,,,fee schedule,,,,,,,,,173.0,,,per diem,,,22.42,,,fee schedule,,,65.25,,,percent of total billed charges,,,10.81,,,fee schedule,,,11.21,,,fee schedule,,,11.03,,,fee schedule,,,204.0,,,per diem,,,10.78,,,fee schedule,,,65.25,,,percent of total billed charges,,,11.21,,,fee schedule,,,11.03,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,10.78,,,fee schedule,,,,,,,,,229.0,,,per diem,,,10.81,,,fee schedule,,,,,,,,,10.81,,,fee schedule,,,,,,,,
PT 97016 Vasopneumatic Device,10391266,CDM,0420,RC,97016,CPT,493,EAPG,,,GP  ,outpatient,facility,,,87.00,26.10,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 90912 Biofeedback Training Initial,10391270,CDM,0420,RC,90912,CPT,,,,,GP  ,outpatient,facility,,,141.00,42.30,61.01,260.0,,87.14,,,percent of total billed charges,,,71.65,,,fee schedule,,,68.81,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,150.74,,,fee schedule,,,61.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",73.07,,,fee schedule,,,164.55,,,fee schedule,,,,,,,,,71.64,,,fee schedule,,,,,,,,,173.0,,,per diem,,,148.55,,,fee schedule,,,105.75,,,percent of total billed charges,,,71.65,,,fee schedule,,,61.01,,,fee schedule,,,73.08,,,fee schedule,,,204.0,,,per diem,,,71.64,,,fee schedule,,,105.75,,,percent of total billed charges,,,61.01,,,fee schedule,,,73.08,,,fee schedule,,,,,,,,,119.85,,,percent of total billed charges,,,64.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,71.64,,,fee schedule,,,,,,,,,229.0,,,per diem,,,71.65,,,fee schedule,,,,,,,,,71.65,,,fee schedule,,,,,,,,
PT 90912 Biofeedback Training Initial,10391270,CDM,0420,RC,90912,CPT,427,EAPG,,,GP  ,outpatient,facility,,,141.00,42.30,128.18,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97022 Whirlpool,10391274,CDM,0420,RC,97022,CPT,,,,,GP  ,outpatient,facility,,,72.00,21.60,14.27,260.0,,68.38,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.28,,,fee schedule,,,51.03,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,30.04,,,fee schedule,,,14.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.56,,,fee schedule,,,32.77,,,fee schedule,,,,,,,,,14.27,,,fee schedule,,,,,,,,,173.0,,,per diem,,,29.60,,,fee schedule,,,54.0,,,percent of total billed charges,,,14.28,,,fee schedule,,,14.75,,,fee schedule,,,14.57,,,fee schedule,,,204.0,,,per diem,,,14.27,,,fee schedule,,,54.0,,,percent of total billed charges,,,14.75,,,fee schedule,,,14.57,,,fee schedule,,,,,,,,,61.20,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,14.27,,,fee schedule,,,,,,,,,229.0,,,per diem,,,14.28,,,fee schedule,,,,,,,,,14.28,,,fee schedule,,,,,,,,
PT 97022 Whirlpool,10391274,CDM,0420,RC,97022,CPT,493,EAPG,,,GP  ,outpatient,facility,,,72.00,21.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 90913 Biofeedback Training Addl Unit,10391278,CDM,0420,RC,90913,CPT,,,,,GP  ,outpatient,facility,,,78.00,23.40,29.05,260.0,,48.20,,,percent of total billed charges,,,29.14,,,fee schedule,,,38.06,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,61.29,,,fee schedule,,,61.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",29.63,,,fee schedule,,,66.72,,,fee schedule,,,,,,,,,29.05,,,fee schedule,,,,,,,,,173.0,,,per diem,,,60.40,,,fee schedule,,,58.5,,,percent of total billed charges,,,29.14,,,fee schedule,,,61.01,,,fee schedule,,,29.72,,,fee schedule,,,204.0,,,per diem,,,29.05,,,fee schedule,,,58.5,,,percent of total billed charges,,,61.01,,,fee schedule,,,29.72,,,fee schedule,,,,,,,,,66.30,,,percent of total billed charges,,,35.88,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.05,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.14,,,fee schedule,,,,,,,,,29.14,,,fee schedule,,,,,,,,
PT 90913 Biofeedback Training Addl Unit,10391278,CDM,0420,RC,90913,CPT,427,EAPG,,,GP  ,outpatient,facility,,,78.00,23.40,78.0,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,78.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97165 EVAL LOW CMPLX,10391314,CDM,0434,RC,97165,CPT,,,,,GO  ,outpatient,facility,,,289.00,86.70,71.16,260.0,,178.60,,,percent of total billed charges,,,94.06,,,fee schedule,,,142.19,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,197.87,,,fee schedule,,,71.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.94,,,fee schedule,,,216.03,,,fee schedule,,,,,,,,,94.06,,,fee schedule,,,,,,,,,173.0,,,per diem,,,195.0,,,fee schedule,,,216.75,,,percent of total billed charges,,,94.06,,,fee schedule,,,71.16,,,fee schedule,,,95.94,,,fee schedule,,,204.0,,,per diem,,,94.06,,,fee schedule,,,216.75,,,percent of total billed charges,,,71.16,,,fee schedule,,,95.94,,,fee schedule,,,,,,,,,245.65,,,percent of total billed charges,,,132.94,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,94.06,,,fee schedule,,,,,,,,,229.0,,,per diem,,,94.06,,,fee schedule,,,,,,,,,94.06,,,fee schedule,,,,,,,,
OT 97165 EVAL LOW CMPLX,10391314,CDM,0434,RC,97165,CPT,270,EAPG,,,GO  ,outpatient,facility,,,289.00,86.70,169.26,261.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,222.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,169.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,186.19,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97166 EVAL MOD CMPLX,10391318,CDM,0434,RC,97166,CPT,,,,,GO  ,outpatient,facility,,,289.00,86.70,71.16,260.0,,178.60,,,percent of total billed charges,,,94.06,,,fee schedule,,,142.19,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,197.87,,,fee schedule,,,71.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.94,,,fee schedule,,,216.03,,,fee schedule,,,,,,,,,94.06,,,fee schedule,,,,,,,,,173.0,,,per diem,,,195.0,,,fee schedule,,,216.75,,,percent of total billed charges,,,94.06,,,fee schedule,,,71.16,,,fee schedule,,,95.94,,,fee schedule,,,204.0,,,per diem,,,94.06,,,fee schedule,,,216.75,,,percent of total billed charges,,,71.16,,,fee schedule,,,95.94,,,fee schedule,,,,,,,,,245.65,,,percent of total billed charges,,,132.94,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,94.06,,,fee schedule,,,,,,,,,229.0,,,per diem,,,94.06,,,fee schedule,,,,,,,,,94.06,,,fee schedule,,,,,,,,
OT 97166 EVAL MOD CMPLX,10391318,CDM,0434,RC,97166,CPT,270,EAPG,,,GO  ,outpatient,facility,,,289.00,86.70,169.26,261.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,222.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,169.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,186.19,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97167 EVAL HIGH CMPLX,10391322,CDM,0434,RC,97167,CPT,,,,,GO  ,outpatient,facility,,,244.00,73.20,71.16,260.0,,150.79,,,percent of total billed charges,,,94.06,,,fee schedule,,,120.05,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,197.87,,,fee schedule,,,71.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.94,,,fee schedule,,,216.03,,,fee schedule,,,,,,,,,94.06,,,fee schedule,,,,,,,,,173.0,,,per diem,,,195.0,,,fee schedule,,,183.0,,,percent of total billed charges,,,94.06,,,fee schedule,,,71.16,,,fee schedule,,,95.94,,,fee schedule,,,204.0,,,per diem,,,94.06,,,fee schedule,,,183.0,,,percent of total billed charges,,,71.16,,,fee schedule,,,95.94,,,fee schedule,,,,,,,,,207.40,,,percent of total billed charges,,,112.24,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,94.06,,,fee schedule,,,,,,,,,229.0,,,per diem,,,94.06,,,fee schedule,,,,,,,,,94.06,,,fee schedule,,,,,,,,
OT 97167 EVAL HIGH CMPLX,10391322,CDM,0434,RC,97167,CPT,270,EAPG,,,GO  ,outpatient,facility,,,244.00,73.20,169.26,261.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,222.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,181.23,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,169.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,186.19,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97168 REEVAL TIME,10391324,CDM,0434,RC,97168,CPT,,,,,GO  ,outpatient,facility,,,148.00,44.40,46.96,260.0,,91.46,,,percent of total billed charges,,,64.70,,,fee schedule,,,72.82,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,136.10,,,fee schedule,,,46.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",66.0,,,fee schedule,,,148.62,,,fee schedule,,,,,,,,,64.71,,,fee schedule,,,,,,,,,173.0,,,per diem,,,134.13,,,fee schedule,,,111.0,,,percent of total billed charges,,,64.70,,,fee schedule,,,46.96,,,fee schedule,,,65.99,,,fee schedule,,,204.0,,,per diem,,,64.71,,,fee schedule,,,111.0,,,percent of total billed charges,,,46.96,,,fee schedule,,,65.99,,,fee schedule,,,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,64.71,,,fee schedule,,,,,,,,,229.0,,,per diem,,,64.70,,,fee schedule,,,,,,,,,64.70,,,fee schedule,,,,,,,,
OT 97168 REEVAL TIME,10391324,CDM,0434,RC,97168,CPT,270,EAPG,,,GO  ,outpatient,facility,,,148.00,44.40,148.0,261.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,222.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,169.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,186.19,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 95852 ROM Measurement Hand,10391336,CDM,0430,RC,95852,CPT,,,,,GO  ,outpatient,facility,,,77.00,23.10,18.17,260.0,,47.59,,,percent of total billed charges,,,18.17,,,fee schedule,,,37.58,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,38.23,,,fee schedule,,,20.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18.55,,,fee schedule,,,41.79,,,fee schedule,,,,,,,,,18.19,,,fee schedule,,,,,,,,,173.0,,,per diem,,,37.68,,,fee schedule,,,57.75,,,percent of total billed charges,,,18.17,,,fee schedule,,,20.11,,,fee schedule,,,18.53,,,fee schedule,,,204.0,,,per diem,,,18.19,,,fee schedule,,,57.75,,,percent of total billed charges,,,20.11,,,fee schedule,,,18.53,,,fee schedule,,,,,,,,,65.45,,,percent of total billed charges,,,35.42,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,18.19,,,fee schedule,,,,,,,,,229.0,,,per diem,,,18.17,,,fee schedule,,,,,,,,,18.17,,,fee schedule,,,,,,,,
OT 95851 ROM Measurement Extrem/Trunk,10391342,CDM,0430,RC,95851,CPT,,,,,GO  ,outpatient,facility,,,94.00,28.20,21.51,260.0,,58.09,,,percent of total billed charges,,,21.51,,,fee schedule,,,45.87,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,45.25,,,fee schedule,,,23.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.96,,,fee schedule,,,49.45,,,fee schedule,,,,,,,,,21.53,,,fee schedule,,,,,,,,,173.0,,,per diem,,,44.59,,,fee schedule,,,70.5,,,percent of total billed charges,,,21.51,,,fee schedule,,,23.86,,,fee schedule,,,21.94,,,fee schedule,,,204.0,,,per diem,,,21.53,,,fee schedule,,,70.5,,,percent of total billed charges,,,23.86,,,fee schedule,,,21.94,,,fee schedule,,,,,,,,,79.90,,,percent of total billed charges,,,43.24,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,21.53,,,fee schedule,,,,,,,,,229.0,,,per diem,,,21.51,,,fee schedule,,,,,,,,,21.51,,,fee schedule,,,,,,,,
OT 99211 EM Level 1,10391346,CDM,0510,RC,99211,CPT,,,,,,outpatient,facility,,,450.00,135.00,11.49,382.5,,278.10,,,percent of total billed charges,,,,,,,,service not payable,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.49,,,fee schedule,,,,,,,,service not payable,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OT 99211 EM Level 1,10391346,CDM,0510,RC,99211,CPT,852,EAPG,,,,outpatient,facility,,,450.00,135.00,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97022 Whirlpool/Fluidotherapy,10391350,CDM,0430,RC,97022,CPT,,,,,GO  ,outpatient,facility,,,72.00,21.60,14.27,260.0,,68.38,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,14.28,,,fee schedule,,,51.03,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,30.04,,,fee schedule,,,14.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",14.56,,,fee schedule,,,32.77,,,fee schedule,,,,,,,,,14.27,,,fee schedule,,,,,,,,,173.0,,,per diem,,,29.60,,,fee schedule,,,54.0,,,percent of total billed charges,,,14.28,,,fee schedule,,,14.75,,,fee schedule,,,14.57,,,fee schedule,,,204.0,,,per diem,,,14.27,,,fee schedule,,,54.0,,,percent of total billed charges,,,14.75,,,fee schedule,,,14.57,,,fee schedule,,,,,,,,,61.20,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,14.27,,,fee schedule,,,,,,,,,229.0,,,per diem,,,14.28,,,fee schedule,,,,,,,,,14.28,,,fee schedule,,,,,,,,
OT 97022 Whirlpool/Fluidotherapy,10391350,CDM,0430,RC,97022,CPT,493,EAPG,,,GO  ,outpatient,facility,,,72.00,21.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97010 Hot Pack/Cold Pack,10391354,CDM,0430,RC,97010,CPT,,,,,GO  ,outpatient,facility,,,118.00,35.40,9.42,260.0,,17.33,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,12.93,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,9.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,173.0,,,per diem,,,,,,,,,88.5,,,percent of total billed charges,,,,,,,,service not payable,9.42,,,fee schedule,,,,,,,,,204.0,,,per diem,,,,,,,,service not payable,88.5,,,percent of total billed charges,,,9.42,,,fee schedule,,,,,,,,service not payable,,,,,,,100.3,,,percent of total billed charges,,,54.28,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,service not payable,,,,,,,229.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OT 97010 Hot Pack/Cold Pack,10391354,CDM,0430,RC,97010,CPT,493,EAPG,,,GO  ,outpatient,facility,,,118.00,35.40,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97018 Paraffin Bath,10391358,CDM,0430,RC,97018,CPT,,,,,GO  ,outpatient,facility,,,61.00,18.30,5.51,260.0,,31.60,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.54,,,fee schedule,,,23.58,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.65,,,fee schedule,,,6.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.62,,,fee schedule,,,12.66,,,fee schedule,,,,,,,,,5.51,,,fee schedule,,,,,,,,,173.0,,,per diem,,,11.49,,,fee schedule,,,45.75,,,percent of total billed charges,,,5.54,,,fee schedule,,,6.26,,,fee schedule,,,5.65,,,fee schedule,,,204.0,,,per diem,,,5.51,,,fee schedule,,,45.75,,,percent of total billed charges,,,6.26,,,fee schedule,,,5.65,,,fee schedule,,,,,,,,,51.85,,,percent of total billed charges,,,28.06,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,5.51,,,fee schedule,,,,,,,,,229.0,,,per diem,,,5.54,,,fee schedule,,,,,,,,,5.54,,,fee schedule,,,,,,,,
OT 97018 Paraffin Bath,10391358,CDM,0430,RC,97018,CPT,493,EAPG,,,GO  ,outpatient,facility,,,61.00,18.30,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97014 Electrical Stimulation Unattend,10391366,CDM,0510,RC,G0281,HCPCS,,,,,,outpatient,facility,,,450.00,135.00,10.5,382.5,,278.10,,,percent of total billed charges,,,10.53,,,fee schedule,,,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,22.15,,,fee schedule,,,12.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.71,,,fee schedule,,,24.11,,,fee schedule,,,,,,,,,10.5,,,fee schedule,,,,,,,,,,,,,,service not payable,21.83,,,fee schedule,,,337.5,,,percent of total billed charges,,,10.53,,,fee schedule,,,12.05,,,fee schedule,,,10.74,,,fee schedule,,,,,,,,service not payable,10.5,,,fee schedule,,,,,,,,service not payable,12.05,,,fee schedule,,,10.74,,,fee schedule,,,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,10.5,,,fee schedule,,,,,,,,,292.5,,,percent of total billed charges,,,10.53,,,fee schedule,,,,,,,,,10.53,,,fee schedule,,,,,,,,
OT 97014 Electrical Stimulation Unattend,10391366,CDM,0510,RC,G0281,HCPCS,16,EAPG,,,,outpatient,facility,,,450.00,135.00,520.18,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97014 Electrical Stimulation Unattend,10391366,CDM,0430,RC,97014,CPT,,,,,GO  ,outpatient,facility,,,90.00,27.00,12.83,260.0,,47.09,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,35.14,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,45.0,,,fee schedule,,,12.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,45.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,173.0,,,per diem,,,,,,,,,67.5,,,percent of total billed charges,,,,,,,,service not payable,12.83,,,fee schedule,,,,,,,,,204.0,,,per diem,,,,,,,,service not payable,67.5,,,percent of total billed charges,,,12.83,,,fee schedule,,,40.5,,,fee schedule,,,,,,,,,76.5,,,percent of total billed charges,,,41.40,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,service not payable,,,,,,,229.0,,,per diem,,,45.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
OT 97014 Electrical Stimulation Unattend,10391366,CDM,0430,RC,97014,CPT,493,EAPG,,,GO  ,outpatient,facility,,,90.00,27.00,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97016 Vasopneumatic Device,10391370,CDM,0430,RC,97016,CPT,,,,,GO  ,outpatient,facility,,,87.00,26.10,10.78,260.0,,56.27,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,10.81,,,fee schedule,,,41.99,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,22.75,,,fee schedule,,,11.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.0,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,10.78,,,fee schedule,,,,,,,,,173.0,,,per diem,,,22.42,,,fee schedule,,,65.25,,,percent of total billed charges,,,10.81,,,fee schedule,,,11.21,,,fee schedule,,,11.03,,,fee schedule,,,204.0,,,per diem,,,10.78,,,fee schedule,,,65.25,,,percent of total billed charges,,,11.21,,,fee schedule,,,11.03,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,10.78,,,fee schedule,,,,,,,,,229.0,,,per diem,,,10.81,,,fee schedule,,,,,,,,,10.81,,,fee schedule,,,,,,,,
OT 97016 Vasopneumatic Device,10391370,CDM,0430,RC,97016,CPT,493,EAPG,,,GO  ,outpatient,facility,,,87.00,26.10,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 90901 Biofeedback Training,10391374,CDM,0430,RC,90901,CPT,,,,,GO  ,outpatient,facility,,,189.00,56.70,36.30,260.0,,116.8,,,percent of total billed charges,,,36.30,,,fee schedule,,,92.23,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,76.36,,,fee schedule,,,,,,,,service not payable,37.03,,,fee schedule,,,83.37,,,fee schedule,,,,,,,,,36.30,,,fee schedule,,,,,,,,,173.0,,,per diem,,,75.26,,,fee schedule,,,141.75,,,percent of total billed charges,,,36.30,,,fee schedule,,,,,,,,service not payable,37.03,,,fee schedule,,,204.0,,,per diem,,,36.30,,,fee schedule,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,37.03,,,fee schedule,,,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,36.30,,,fee schedule,,,,,,,,,229.0,,,per diem,,,36.30,,,fee schedule,,,,,,,,,36.30,,,fee schedule,,,,,,,,
OT 90901 Biofeedback Training,10391374,CDM,0430,RC,90901,CPT,427,EAPG,,,GO  ,outpatient,facility,,,189.00,56.70,128.18,264.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,224.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,128.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,199.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,219.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97605 Wound Vac Therapy </  50 cm,10391378,CDM,0430,RC,97605,CPT,,,,,GO  ,outpatient,facility,,,375.00,112.50,39.15,318.75,,231.75,,,percent of total billed charges,,,39.15,,,fee schedule,,,183.0,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,82.37,,,fee schedule,,,,,,,,,39.98,,,fee schedule,,,90.04,,,fee schedule,,,,,,,,,39.20,,,fee schedule,,,,,,,,,173.0,,,per diem,,,81.17,,,fee schedule,,,281.25,,,percent of total billed charges,,,39.15,,,fee schedule,,,,,,,,,39.93,,,fee schedule,,,204.0,,,per diem,,,39.20,,,fee schedule,,,281.25,,,percent of total billed charges,,,39.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",39.93,,,fee schedule,,,,,,,,,318.75,,,percent of total billed charges,,,172.5,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,39.20,,,fee schedule,,,,,,,,,229.0,,,per diem,,,39.15,,,fee schedule,,,,,,,,,39.15,,,fee schedule,,,,,,,,
OT 97605 Wound Vac Therapy </  50 cm,10391378,CDM,0430,RC,97605,CPT,16,EAPG,,,GO  ,outpatient,facility,,,375.00,112.50,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97597 Selective Debridement </ 20 cm,10391382,CDM,0430,RC,97597,CPT,,,,,GO  ,outpatient,facility,,,341.00,102.30,88.29,289.85,,210.74,,,percent of total billed charges,,,88.29,,,fee schedule,,,166.41,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,185.74,,,fee schedule,,,,,,,,,90.09,,,fee schedule,,,202.86,,,fee schedule,,,,,,,,,88.32,,,fee schedule,,,,,,,,,173.0,,,per diem,,,183.05,,,fee schedule,,,255.75,,,percent of total billed charges,,,88.29,,,fee schedule,,,,,,,,,90.06,,,fee schedule,,,204.0,,,per diem,,,88.32,,,fee schedule,,,255.75,,,percent of total billed charges,,,89.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",90.06,,,fee schedule,,,,,,,,,289.85,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,88.32,,,fee schedule,,,,,,,,,229.0,,,per diem,,,88.29,,,fee schedule,,,,,,,,,88.29,,,fee schedule,,,,,,,,
OT 97597 Selective Debridement </ 20 cm,10391382,CDM,0430,RC,97597,CPT,16,EAPG,,,GO  ,outpatient,facility,,,341.00,102.30,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97598 Selective Debridement >20 cm,10391386,CDM,0430,RC,97598,CPT,,,,,GO  ,outpatient,facility,,,341.00,102.30,39.46,289.85,,210.74,,,percent of total billed charges,,,39.60,,,fee schedule,,,166.41,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,83.30,,,fee schedule,,,,,,,,,40.25,,,fee schedule,,,90.63,,,fee schedule,,,,,,,,,39.46,,,fee schedule,,,,,,,,,173.0,,,per diem,,,82.09,,,fee schedule,,,255.75,,,percent of total billed charges,,,39.60,,,fee schedule,,,,,,,,,40.39,,,fee schedule,,,204.0,,,per diem,,,39.46,,,fee schedule,,,255.75,,,percent of total billed charges,,,40.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",40.39,,,fee schedule,,,,,,,,,289.85,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,39.46,,,fee schedule,,,,,,,,,229.0,,,per diem,,,39.60,,,fee schedule,,,,,,,,,39.60,,,fee schedule,,,,,,,,
OT 97598 Selective Debridement >20 cm,10391386,CDM,0430,RC,97598,CPT,18,EAPG,,,GO  ,outpatient,facility,,,341.00,102.30,341.0,6298.20,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6298.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5353.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2903.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3193.81,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 29105 Apply Long Arm Splint,10391390,CDM,0430,RC,29105,CPT,,,,,GO  ,outpatient,facility,,,321.00,96.30,147.66,272.85,,198.38,,,percent of total billed charges,,,,,,,,,156.65,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,240.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,240.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,272.85,,,percent of total billed charges,,,147.66,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29105 Apply Long Arm Splint,10391390,CDM,0430,RC,29105,CPT,05101,APC,,,GO  ,outpatient,facility,,,321.00,96.30,145.14,347.54,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,318.32,,,fee schedule,,,145.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",154.35,,,fee schedule,,,347.54,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,313.71,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,145.14,,,fee schedule,,,154.35,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,145.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",154.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,152.83,,,fee schedule,,,,,,,,
OT 29105 Apply Long Arm Splint,10391390,CDM,0430,RC,29105,CPT,40,EAPG,,,GO  ,outpatient,facility,,,321.00,96.30,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 29125 Apply Short Arm Splint Static,10391394,CDM,0430,RC,29125,CPT,,,,,GO  ,outpatient,facility,,,351.00,105.30,161.46,298.35,,216.92,,,percent of total billed charges,,,,,,,,,171.29,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,263.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,263.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,298.35,,,percent of total billed charges,,,161.46,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29125 Apply Short Arm Splint Static,10391394,CDM,0430,RC,29125,CPT,05734,APC,,,GO  ,outpatient,facility,,,351.00,105.30,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
OT 29125 Apply Short Arm Splint Static,10391394,CDM,0430,RC,29125,CPT,40,EAPG,,,GO  ,outpatient,facility,,,351.00,105.30,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 29126 Apply Short Arm Splint Dynamic,10391398,CDM,0430,RC,29126,CPT,,,,,GO  ,outpatient,facility,,,168.00,50.40,77.28,260.0,,103.82,,,percent of total billed charges,,,,,,,,,81.98,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.80,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29126 Apply Short Arm Splint Dynamic,10391398,CDM,0430,RC,29126,CPT,05734,APC,,,GO  ,outpatient,facility,,,168.00,50.40,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
OT 29126 Apply Short Arm Splint Dynamic,10391398,CDM,0430,RC,29126,CPT,40,EAPG,,,GO  ,outpatient,facility,,,168.00,50.40,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 29130 Apply Finger Splint Static,10391402,CDM,0430,RC,29130,CPT,,,,,GO  ,outpatient,facility,,,255.00,76.50,117.3,260.0,,157.59,,,percent of total billed charges,,,,,,,,,124.44,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,191.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,191.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.75,,,percent of total billed charges,,,117.3,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29130 Apply Finger Splint Static,10391402,CDM,0430,RC,29130,CPT,05734,APC,,,GO  ,outpatient,facility,,,255.00,76.50,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
OT 29130 Apply Finger Splint Static,10391402,CDM,0430,RC,29130,CPT,40,EAPG,,,GO  ,outpatient,facility,,,255.00,76.50,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 29131 Apply Finger Splint Dynamic,10391406,CDM,0430,RC,29131,CPT,,,,,GO  ,outpatient,facility,,,168.00,50.40,77.28,260.0,,103.82,,,percent of total billed charges,,,,,,,,,81.98,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.80,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29131 Apply Finger Splint Dynamic,10391406,CDM,0430,RC,29131,CPT,05733,APC,,,GO  ,outpatient,facility,,,168.00,50.40,54.63,130.83,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,119.83,,,fee schedule,,,54.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",58.10,,,fee schedule,,,130.83,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,118.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,54.63,,,fee schedule,,,58.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,54.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",58.10,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,57.53,,,fee schedule,,,,,,,,
OT 29131 Apply Finger Splint Dynamic,10391406,CDM,0430,RC,29131,CPT,40,EAPG,,,GO  ,outpatient,facility,,,168.00,50.40,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97535 Self Care/Home Mgmt Training,10391410,CDM,0430,RC,97535,CPT,,,,,GO  ,outpatient,facility,,,152.00,45.60,27.91,260.0,,103.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,29.87,,,fee schedule,,,77.52,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,62.85,,,fee schedule,,,27.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.48,,,fee schedule,,,68.64,,,fee schedule,,,,,,,,,29.88,,,fee schedule,,,,,,,,,173.0,,,per diem,,,61.93,,,fee schedule,,,114.0,,,percent of total billed charges,,,29.87,,,fee schedule,,,27.91,,,fee schedule,,,30.47,,,fee schedule,,,204.0,,,per diem,,,29.88,,,fee schedule,,,114.0,,,percent of total billed charges,,,27.91,,,fee schedule,,,30.47,,,fee schedule,,,,,,,,,129.20,,,percent of total billed charges,,,69.92,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.88,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.87,,,fee schedule,,,,,,,,,29.87,,,fee schedule,,,,,,,,
OT 97535 Self Care/Home Mgmt Training,10391410,CDM,0430,RC,97535,CPT,493,EAPG,,,GO  ,outpatient,facility,,,152.00,45.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97110 Therapeutic Proc/Exercise Units,10391414,CDM,0430,RC,97110,CPT,,,,,GO  ,outpatient,facility,,,195.00,58.50,24.88,260.0,,96.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,26.96,,,fee schedule,,,71.74,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,56.72,,,fee schedule,,,24.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",27.51,,,fee schedule,,,61.95,,,fee schedule,,,,,,,,,26.97,,,fee schedule,,,,,,,,,173.0,,,per diem,,,55.90,,,fee schedule,,,146.25,,,percent of total billed charges,,,26.96,,,fee schedule,,,24.88,,,fee schedule,,,27.5,,,fee schedule,,,204.0,,,per diem,,,26.97,,,fee schedule,,,146.25,,,percent of total billed charges,,,24.88,,,fee schedule,,,27.5,,,fee schedule,,,,,,,,,165.75,,,percent of total billed charges,,,89.70,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,26.97,,,fee schedule,,,,,,,,,229.0,,,per diem,,,26.96,,,fee schedule,,,,,,,,,26.96,,,fee schedule,,,,,,,,
OT 97110 Therapeutic Proc/Exercise Units,10391414,CDM,0430,RC,97110,CPT,269,EAPG,,,GO  ,outpatient,facility,,,195.00,58.50,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97140 Manual Therapy Technique Units,10391418,CDM,0430,RC,97140,CPT,,,,,GO  ,outpatient,facility,,,155.00,46.50,23.28,260.0,,89.40,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,25.46,,,fee schedule,,,66.71,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,53.55,,,fee schedule,,,23.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",25.97,,,fee schedule,,,58.47,,,fee schedule,,,,,,,,,25.46,,,fee schedule,,,,,,,,,173.0,,,per diem,,,52.77,,,fee schedule,,,116.25,,,percent of total billed charges,,,25.46,,,fee schedule,,,23.28,,,fee schedule,,,25.97,,,fee schedule,,,204.0,,,per diem,,,25.46,,,fee schedule,,,116.25,,,percent of total billed charges,,,23.28,,,fee schedule,,,25.97,,,fee schedule,,,,,,,,,131.75,,,percent of total billed charges,,,71.30,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,25.46,,,fee schedule,,,,,,,,,229.0,,,per diem,,,25.46,,,fee schedule,,,,,,,,,25.46,,,fee schedule,,,,,,,,
OT 97140 Manual Therapy Technique Units,10391418,CDM,0430,RC,97140,CPT,269,EAPG,,,GO  ,outpatient,facility,,,155.00,46.50,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97530 Therapeutic Activity Units,10391422,CDM,0430,RC,97530,CPT,,,,,GO  ,outpatient,facility,,,173.00,51.90,30.83,260.0,,103.76,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,32.17,,,fee schedule,,,77.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,67.67,,,fee schedule,,,30.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",32.84,,,fee schedule,,,73.95,,,fee schedule,,,,,,,,,32.20,,,fee schedule,,,,,,,,,173.0,,,per diem,,,66.69,,,fee schedule,,,129.75,,,percent of total billed charges,,,32.17,,,fee schedule,,,30.83,,,fee schedule,,,32.81,,,fee schedule,,,204.0,,,per diem,,,32.20,,,fee schedule,,,129.75,,,percent of total billed charges,,,30.83,,,fee schedule,,,32.81,,,fee schedule,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,32.20,,,fee schedule,,,,,,,,,229.0,,,per diem,,,32.17,,,fee schedule,,,,,,,,,32.17,,,fee schedule,,,,,,,,
OT 97530 Therapeutic Activity Units,10391422,CDM,0430,RC,97530,CPT,269,EAPG,,,GO  ,outpatient,facility,,,173.00,51.90,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97124 Massage Units,10391426,CDM,0430,RC,97124,CPT,,,,,GO  ,outpatient,facility,,,82.00,24.60,19.56,260.0,,78.81,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,27.56,,,fee schedule,,,58.81,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,57.98,,,fee schedule,,,19.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",28.13,,,fee schedule,,,63.35,,,fee schedule,,,,,,,,,27.58,,,fee schedule,,,,,,,,,173.0,,,per diem,,,57.14,,,fee schedule,,,61.5,,,percent of total billed charges,,,27.56,,,fee schedule,,,19.56,,,fee schedule,,,28.11,,,fee schedule,,,204.0,,,per diem,,,27.58,,,fee schedule,,,61.5,,,percent of total billed charges,,,19.56,,,fee schedule,,,28.11,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,27.58,,,fee schedule,,,,,,,,,229.0,,,per diem,,,27.56,,,fee schedule,,,,,,,,,27.56,,,fee schedule,,,,,,,,
OT 97124 Massage Units,10391426,CDM,0430,RC,97124,CPT,493,EAPG,,,GO  ,outpatient,facility,,,82.00,24.60,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97750 Phys Performance Test/Measure,10391430,CDM,0430,RC,97750,CPT,,,,,GO  ,outpatient,facility,,,148.00,44.40,24.32,260.0,,91.46,,,percent of total billed charges,,,31.04,,,fee schedule,,,72.22,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,65.29,,,fee schedule,,,24.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",31.67,,,fee schedule,,,71.33,,,fee schedule,,,,,,,,,31.05,,,fee schedule,,,,,,,,,173.0,,,per diem,,,64.34,,,fee schedule,,,111.0,,,percent of total billed charges,,,31.04,,,fee schedule,,,24.32,,,fee schedule,,,31.66,,,fee schedule,,,204.0,,,per diem,,,31.05,,,fee schedule,,,111.0,,,percent of total billed charges,,,24.32,,,fee schedule,,,31.66,,,fee schedule,,,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,31.05,,,fee schedule,,,,,,,,,229.0,,,per diem,,,31.04,,,fee schedule,,,,,,,,,31.04,,,fee schedule,,,,,,,,
OT 97750 Phys Performance Test/Measure,10391430,CDM,0430,RC,97750,CPT,269,EAPG,,,GO  ,outpatient,facility,,,148.00,44.40,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97542 Wheelchair Management Units,10391434,CDM,0430,RC,97542,CPT,,,,,GO  ,outpatient,facility,,,137.00,41.10,23.44,260.0,,91.65,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,28.79,,,fee schedule,,,68.39,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,60.57,,,fee schedule,,,23.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",29.38,,,fee schedule,,,66.15,,,fee schedule,,,,,,,,,28.80,,,fee schedule,,,,,,,,,173.0,,,per diem,,,59.69,,,fee schedule,,,102.75,,,percent of total billed charges,,,28.79,,,fee schedule,,,23.44,,,fee schedule,,,29.37,,,fee schedule,,,204.0,,,per diem,,,28.80,,,fee schedule,,,102.75,,,percent of total billed charges,,,23.44,,,fee schedule,,,29.37,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,28.80,,,fee schedule,,,,,,,,,229.0,,,per diem,,,28.79,,,fee schedule,,,,,,,,,28.79,,,fee schedule,,,,,,,,
OT 97542 Wheelchair Management Units,10391434,CDM,0430,RC,97542,CPT,269,EAPG,,,GO  ,outpatient,facility,,,137.00,41.10,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97112 Neuromuscular Reeducation Units,10391438,CDM,0430,RC,97112,CPT,,,,,GO  ,outpatient,facility,,,160.00,48.00,25.96,260.0,,99.80,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,30.01,,,fee schedule,,,74.47,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,63.13,,,fee schedule,,,25.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.62,,,fee schedule,,,68.95,,,fee schedule,,,,,,,,,30.02,,,fee schedule,,,,,,,,,173.0,,,per diem,,,62.22,,,fee schedule,,,120.0,,,percent of total billed charges,,,30.01,,,fee schedule,,,25.96,,,fee schedule,,,30.61,,,fee schedule,,,204.0,,,per diem,,,30.02,,,fee schedule,,,120.0,,,percent of total billed charges,,,25.96,,,fee schedule,,,30.61,,,fee schedule,,,,,,,,,136.0,,,percent of total billed charges,,,73.60,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,30.02,,,fee schedule,,,,,,,,,229.0,,,per diem,,,30.01,,,fee schedule,,,,,,,,,30.01,,,fee schedule,,,,,,,,
OT 97112 Neuromuscular Reeducation Units,10391438,CDM,0430,RC,97112,CPT,269,EAPG,,,GO  ,outpatient,facility,,,160.00,48.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97537 Community/Work Reintegration,10391442,CDM,0430,RC,97537,CPT,,,,,GO  ,outpatient,facility,,,100.00,30.00,22.81,260.0,,90.62,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,29.66,,,fee schedule,,,67.62,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,62.39,,,fee schedule,,,22.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.27,,,fee schedule,,,68.16,,,fee schedule,,,,,,,,,29.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,61.49,,,fee schedule,,,75.0,,,percent of total billed charges,,,29.66,,,fee schedule,,,22.81,,,fee schedule,,,30.25,,,fee schedule,,,204.0,,,per diem,,,29.68,,,fee schedule,,,75.0,,,percent of total billed charges,,,22.81,,,fee schedule,,,30.25,,,fee schedule,,,,,,,,,85.0,,,percent of total billed charges,,,46.0,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.66,,,fee schedule,,,,,,,,,29.66,,,fee schedule,,,,,,,,
OT 97537 Community/Work Reintegration,10391442,CDM,0430,RC,97537,CPT,269,EAPG,,,GO  ,outpatient,facility,,,100.00,30.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97129 Cognitive Initial Units,10391446,CDM,0430,RC,97129,CPT,,,,,GO  ,outpatient,facility,,,196.00,58.80,20.68,260.0,,121.13,,,percent of total billed charges,,,20.71,,,fee schedule,,,96.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,43.57,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.09,,,fee schedule,,,47.51,,,fee schedule,,,,,,,,,20.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,42.94,,,fee schedule,,,147.0,,,percent of total billed charges,,,20.71,,,fee schedule,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,204.0,,,per diem,,,20.68,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,20.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,20.71,,,fee schedule,,,,,,,,,20.71,,,fee schedule,,,,,,,,
OT 97129 Cognitive Initial Units,10391446,CDM,0430,RC,97129,CPT,269,EAPG,,,GO  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97130 Cognitive Subsequent Units,10391454,CDM,0430,RC,97130,CPT,,,,,GO  ,outpatient,facility,,,196.00,58.80,19.75,260.0,,121.13,,,percent of total billed charges,,,19.78,,,fee schedule,,,96.43,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,41.61,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.14,,,fee schedule,,,45.36,,,fee schedule,,,,,,,,,19.75,,,fee schedule,,,,,,,,,173.0,,,per diem,,,41.0,,,fee schedule,,,147.0,,,percent of total billed charges,,,19.78,,,fee schedule,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,204.0,,,per diem,,,19.75,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,19.75,,,fee schedule,,,,,,,,,229.0,,,per diem,,,19.78,,,fee schedule,,,,,,,,,19.78,,,fee schedule,,,,,,,,
OT 97130 Cognitive Subsequent Units,10391454,CDM,0430,RC,97130,CPT,269,EAPG,,,GO  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97150 Group Therapy Units,10391458,CDM,0430,RC,97150,CPT,,,,,GO  ,outpatient,facility,,,126.00,37.80,16.33,260.0,,52.30,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,16.35,,,fee schedule,,,39.03,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,34.40,,,fee schedule,,,16.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.66,,,fee schedule,,,37.52,,,fee schedule,,,,,,,,,16.33,,,fee schedule,,,,,,,,,173.0,,,per diem,,,33.90,,,fee schedule,,,94.5,,,percent of total billed charges,,,16.35,,,fee schedule,,,16.60,,,fee schedule,,,16.68,,,fee schedule,,,204.0,,,per diem,,,16.33,,,fee schedule,,,94.5,,,percent of total billed charges,,,16.60,,,fee schedule,,,16.68,,,fee schedule,,,,,,,,,107.10,,,percent of total billed charges,,,57.96,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,16.33,,,fee schedule,,,,,,,,,229.0,,,per diem,,,16.35,,,fee schedule,,,,,,,,,16.35,,,fee schedule,,,,,,,,
OT 97150 Group Therapy Units,10391458,CDM,0430,RC,97150,CPT,269,EAPG,,,GO  ,outpatient,facility,,,126.00,37.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97113 Aquatic Therapy Units,10391462,CDM,0430,RC,97113,CPT,,,,,GO  ,outpatient,facility,,,173.00,51.90,27.13,260.0,,127.21,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.02,,,fee schedule,,,94.92,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,71.56,,,fee schedule,,,27.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",34.74,,,fee schedule,,,78.22,,,fee schedule,,,,,,,,,34.06,,,fee schedule,,,,,,,,,173.0,,,per diem,,,70.52,,,fee schedule,,,129.75,,,percent of total billed charges,,,34.02,,,fee schedule,,,27.13,,,fee schedule,,,34.70,,,fee schedule,,,204.0,,,per diem,,,34.06,,,fee schedule,,,129.75,,,percent of total billed charges,,,27.13,,,fee schedule,,,34.70,,,fee schedule,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,34.06,,,fee schedule,,,,,,,,,229.0,,,per diem,,,34.02,,,fee schedule,,,,,,,,,34.02,,,fee schedule,,,,,,,,
OT 97113 Aquatic Therapy Units,10391462,CDM,0430,RC,97113,CPT,269,EAPG,,,GO  ,outpatient,facility,,,173.00,51.90,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97033 Iontophoresis Units,10391466,CDM,0430,RC,97033,CPT,,,,,GO  ,outpatient,facility,,,149.00,44.70,13.63,260.0,,95.80,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,17.43,,,fee schedule,,,71.48,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,36.66,,,fee schedule,,,13.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17.77,,,fee schedule,,,40.0,,,fee schedule,,,,,,,,,17.42,,,fee schedule,,,,,,,,,173.0,,,per diem,,,36.13,,,fee schedule,,,111.75,,,percent of total billed charges,,,17.43,,,fee schedule,,,13.63,,,fee schedule,,,17.78,,,fee schedule,,,204.0,,,per diem,,,17.42,,,fee schedule,,,111.75,,,percent of total billed charges,,,13.63,,,fee schedule,,,17.78,,,fee schedule,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,17.42,,,fee schedule,,,,,,,,,229.0,,,per diem,,,17.43,,,fee schedule,,,,,,,,,17.43,,,fee schedule,,,,,,,,
OT 97033 Iontophoresis Units,10391466,CDM,0430,RC,97033,CPT,493,EAPG,,,GO  ,outpatient,facility,,,149.00,44.70,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97035 Ultrasound Units,10391470,CDM,0430,RC,97035,CPT,,,,,GO  ,outpatient,facility,,,195.00,58.50,10.32,260.0,,38.22,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.93,,,fee schedule,,,28.52,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.20,,,fee schedule,,,10.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.17,,,fee schedule,,,29.65,,,fee schedule,,,,,,,,,12.91,,,fee schedule,,,,,,,,,173.0,,,per diem,,,26.81,,,fee schedule,,,146.25,,,percent of total billed charges,,,12.93,,,fee schedule,,,10.32,,,fee schedule,,,13.19,,,fee schedule,,,204.0,,,per diem,,,12.91,,,fee schedule,,,146.25,,,percent of total billed charges,,,10.32,,,fee schedule,,,13.19,,,fee schedule,,,,,,,,,165.75,,,percent of total billed charges,,,89.70,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,12.91,,,fee schedule,,,,,,,,,229.0,,,per diem,,,12.93,,,fee schedule,,,,,,,,,12.93,,,fee schedule,,,,,,,,
OT 97035 Ultrasound Units,10391470,CDM,0430,RC,97035,CPT,493,EAPG,,,GO  ,outpatient,facility,,,195.00,58.50,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97032 Electrical Stimulation Attended,10391474,CDM,0430,RC,97032,CPT,,,,,GO  ,outpatient,facility,,,120.00,36.00,13.30,260.0,,56.99,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.33,,,fee schedule,,,42.52,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.05,,,fee schedule,,,15.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.57,,,fee schedule,,,30.56,,,fee schedule,,,,,,,,,13.30,,,fee schedule,,,,,,,,,173.0,,,per diem,,,27.64,,,fee schedule,,,90.0,,,percent of total billed charges,,,13.33,,,fee schedule,,,15.99,,,fee schedule,,,13.6,,,fee schedule,,,204.0,,,per diem,,,13.30,,,fee schedule,,,90.0,,,percent of total billed charges,,,15.99,,,fee schedule,,,13.6,,,fee schedule,,,,,,,,,102.0,,,percent of total billed charges,,,55.20,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,13.30,,,fee schedule,,,,,,,,,229.0,,,per diem,,,13.33,,,fee schedule,,,,,,,,,13.33,,,fee schedule,,,,,,,,
OT 97032 Electrical Stimulation Attended,10391474,CDM,0430,RC,97032,CPT,493,EAPG,,,GO  ,outpatient,facility,,,120.00,36.00,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97034 Contrast Bath Units,10391478,CDM,0430,RC,97034,CPT,,,,,GO  ,outpatient,facility,,,115.00,34.50,12.28,260.0,,53.52,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.64,,,fee schedule,,,39.94,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.60,,,fee schedule,,,12.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.86,,,fee schedule,,,28.97,,,fee schedule,,,,,,,,,12.61,,,fee schedule,,,,,,,,,173.0,,,per diem,,,26.21,,,fee schedule,,,86.25,,,percent of total billed charges,,,12.64,,,fee schedule,,,12.28,,,fee schedule,,,12.89,,,fee schedule,,,204.0,,,per diem,,,12.61,,,fee schedule,,,86.25,,,percent of total billed charges,,,12.28,,,fee schedule,,,12.89,,,fee schedule,,,,,,,,,97.75,,,percent of total billed charges,,,52.90,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,12.61,,,fee schedule,,,,,,,,,229.0,,,per diem,,,12.64,,,fee schedule,,,,,,,,,12.64,,,fee schedule,,,,,,,,
OT 97034 Contrast Bath Units,10391478,CDM,0430,RC,97034,CPT,493,EAPG,,,GO  ,outpatient,facility,,,115.00,34.50,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97760 Orthotic Management/Training,10391482,CDM,0430,RC,97760,CPT,,,,,GO  ,outpatient,facility,,,170.00,51.00,26.81,260.0,,105.06,,,percent of total billed charges,,,42.51,,,fee schedule,,,82.96,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,89.42,,,fee schedule,,,26.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",43.42,,,fee schedule,,,97.77,,,fee schedule,,,,,,,,,42.57,,,fee schedule,,,,,,,,,173.0,,,per diem,,,88.13,,,fee schedule,,,127.5,,,percent of total billed charges,,,42.51,,,fee schedule,,,26.81,,,fee schedule,,,43.36,,,fee schedule,,,204.0,,,per diem,,,42.57,,,fee schedule,,,127.5,,,percent of total billed charges,,,26.81,,,fee schedule,,,43.36,,,fee schedule,,,,,,,,,144.5,,,percent of total billed charges,,,78.20,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,42.57,,,fee schedule,,,,,,,,,229.0,,,per diem,,,42.51,,,fee schedule,,,,,,,,,42.51,,,fee schedule,,,,,,,,
OT 97760 Orthotic Management/Training,10391482,CDM,0430,RC,97760,CPT,269,EAPG,,,GO  ,outpatient,facility,,,170.00,51.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 97763 Subsequent Orth Mgmt/Training,10391486,CDM,0430,RC,97763,CPT,,,,,GO  ,outpatient,facility,,,137.00,41.10,43.61,260.0,,84.67,,,percent of total billed charges,,,46.23,,,fee schedule,,,67.40,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,97.25,,,fee schedule,,,43.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",47.25,,,fee schedule,,,106.38,,,fee schedule,,,,,,,,,46.32,,,fee schedule,,,,,,,,,173.0,,,per diem,,,95.84,,,fee schedule,,,102.75,,,percent of total billed charges,,,46.23,,,fee schedule,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,204.0,,,per diem,,,46.32,,,fee schedule,,,102.75,,,percent of total billed charges,,,43.61,,,fee schedule,,,47.15,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,46.32,,,fee schedule,,,,,,,,,229.0,,,per diem,,,46.23,,,fee schedule,,,,,,,,,46.23,,,fee schedule,,,,,,,,
OT 97763 Subsequent Orth Mgmt/Training,10391486,CDM,0430,RC,97763,CPT,269,EAPG,,,GO  ,outpatient,facility,,,137.00,41.10,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT 29086 Finger Cast Units,10391490,CDM,0430,RC,29086,CPT,,,,,GO  ,outpatient,facility,,,419.00,125.70,173.0,356.15,,258.94,,,percent of total billed charges,,,,,,,,,204.47,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,314.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,314.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,356.15,,,percent of total billed charges,,,192.74,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29086 Finger Cast Units,10391490,CDM,0430,RC,29086,CPT,05101,APC,,,GO  ,outpatient,facility,,,419.00,125.70,145.14,347.54,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,318.32,,,fee schedule,,,145.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",154.35,,,fee schedule,,,347.54,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,313.71,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,145.14,,,fee schedule,,,154.35,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,145.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",154.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,152.83,,,fee schedule,,,,,,,,
OT 29086 Finger Cast Units,10391490,CDM,0430,RC,29086,CPT,39,EAPG,,,GO  ,outpatient,facility,,,419.00,125.70,261.60,997.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,848.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,355.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,390.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ST 97537 Community/Work Re-Integration,10391526,CDM,0440,RC,97537,CPT,,,,,GN  ,outpatient,facility,,,100.00,30.00,22.81,260.0,,90.62,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,29.66,,,fee schedule,,,67.62,,,fee schedule,,,50.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,62.39,,,fee schedule,,,22.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",30.27,,,fee schedule,,,68.16,,,fee schedule,,,,,,,,,29.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,61.49,,,fee schedule,,,75.0,,,percent of total billed charges,,,29.66,,,fee schedule,,,22.81,,,fee schedule,,,30.25,,,fee schedule,,,204.0,,,per diem,,,29.68,,,fee schedule,,,75.0,,,percent of total billed charges,,,22.81,,,fee schedule,,,30.25,,,fee schedule,,,,,,,,,85.0,,,percent of total billed charges,,,46.0,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,29.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,29.66,,,fee schedule,,,,,,,,,29.66,,,fee schedule,,,,,,,,
ST 97537 Community/Work Re-Integration,10391526,CDM,0440,RC,97537,CPT,269,EAPG,,,GN  ,outpatient,facility,,,100.00,30.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ST 97110 Therapeutic Exercise,10391528,CDM,0440,RC,97110,CPT,,,,,GN  ,outpatient,facility,,,195.00,58.50,24.88,260.0,,96.14,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,26.96,,,fee schedule,,,71.74,,,fee schedule,,,98.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,56.72,,,fee schedule,,,24.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",27.51,,,fee schedule,,,61.95,,,fee schedule,,,,,,,,,26.97,,,fee schedule,,,,,,,,,173.0,,,per diem,,,55.90,,,fee schedule,,,146.25,,,percent of total billed charges,,,26.96,,,fee schedule,,,24.88,,,fee schedule,,,27.5,,,fee schedule,,,204.0,,,per diem,,,26.97,,,fee schedule,,,146.25,,,percent of total billed charges,,,24.88,,,fee schedule,,,27.5,,,fee schedule,,,,,,,,,165.75,,,percent of total billed charges,,,89.70,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,26.97,,,fee schedule,,,,,,,,,229.0,,,per diem,,,26.96,,,fee schedule,,,,,,,,,26.96,,,fee schedule,,,,,,,,
ST 97110 Therapeutic Exercise,10391528,CDM,0440,RC,97110,CPT,269,EAPG,,,GN  ,outpatient,facility,,,195.00,58.50,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ST 97129 Ther IVNTJ Cog Funct 1st 15min,10391530,CDM,0440,RC,97129,CPT,,,,,GN  ,outpatient,facility,,,196.00,58.80,20.68,260.0,,121.13,,,percent of total billed charges,,,20.71,,,fee schedule,,,96.43,,,fee schedule,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,43.57,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21.09,,,fee schedule,,,47.51,,,fee schedule,,,,,,,,,20.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,42.94,,,fee schedule,,,147.0,,,percent of total billed charges,,,20.71,,,fee schedule,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,204.0,,,per diem,,,20.68,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,21.12,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,20.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,20.71,,,fee schedule,,,,,,,,,20.71,,,fee schedule,,,,,,,,
ST 97129 Ther IVNTJ Cog Funct 1st 15min,10391530,CDM,0440,RC,97129,CPT,269,EAPG,,,GN  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ST 97130 Ther IVNTJ ea addl 15 min,10391532,CDM,0440,RC,97130,CPT,,,,,GN  ,outpatient,facility,,,196.00,58.80,19.75,260.0,,121.13,,,percent of total billed charges,,,19.78,,,fee schedule,,,96.43,,,fee schedule,,,98.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,41.61,,,fee schedule,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.14,,,fee schedule,,,45.36,,,fee schedule,,,,,,,,,19.75,,,fee schedule,,,,,,,,,173.0,,,per diem,,,41.0,,,fee schedule,,,147.0,,,percent of total billed charges,,,19.78,,,fee schedule,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,204.0,,,per diem,,,19.75,,,fee schedule,,,147.0,,,percent of total billed charges,,,25.98,,,fee schedule,,,20.18,,,fee schedule,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,19.75,,,fee schedule,,,,,,,,,229.0,,,per diem,,,19.78,,,fee schedule,,,,,,,,,19.78,,,fee schedule,,,,,,,,
ST 97130 Ther IVNTJ ea addl 15 min,10391532,CDM,0440,RC,97130,CPT,269,EAPG,,,GN  ,outpatient,facility,,,196.00,58.80,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Auditory Rehab Evaluation - Speech Therapist Compl,10391564,CDM,0444,RC,92626,CPT,,,,,GN  ,outpatient,facility,,,434.00,130.20,173.0,368.90,,268.21,,,percent of total billed charges,,,,,,,,,211.79,,,percent of total billed charges,,,218.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,325.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,325.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,368.90,,,percent of total billed charges,,,199.64,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Auditory Rehab Evaluation - Speech Therapist Compl,10391564,CDM,0444,RC,92626,CPT,05721,APC,,,GN  ,outpatient,facility,,,434.00,130.20,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Auditory Rehab Evaluation - Speech Therapist Compl,10391564,CDM,0444,RC,92626,CPT,272,EAPG,,,GN  ,outpatient,facility,,,434.00,130.20,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bedside Dysphagia Evaluation - Speech Therapist Co,10391565,CDM,0444,RC,92610,CPT,,,,,GN  ,outpatient,facility,,,503.00,150.90,77.95,427.55,,310.85,,,percent of total billed charges,,,77.99,,,fee schedule,,,245.46,,,percent of total billed charges,,,253.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,164.07,,,fee schedule,,,106.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",79.51,,,fee schedule,,,179.04,,,fee schedule,,,,,,,,,77.95,,,fee schedule,,,,,,,,,173.0,,,per diem,,,161.69,,,fee schedule,,,377.25,,,percent of total billed charges,,,77.99,,,fee schedule,,,106.01,,,fee schedule,,,79.55,,,fee schedule,,,204.0,,,per diem,,,77.95,,,fee schedule,,,377.25,,,percent of total billed charges,,,106.01,,,fee schedule,,,79.55,,,fee schedule,,,,,,,,,427.55,,,percent of total billed charges,,,231.38,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,77.95,,,fee schedule,,,,,,,,,229.0,,,per diem,,,77.99,,,fee schedule,,,,,,,,,77.99,,,fee schedule,,,,,,,,
Bedside Dysphagia Evaluation - Speech Therapist Co,10391565,CDM,0444,RC,92610,CPT,272,EAPG,,,GN  ,outpatient,facility,,,503.00,150.90,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Augmentative Treatment/Training - Speech Therapist,10391566,CDM,0440,RC,92609,CPT,,,,,GN  ,outpatient,facility,,,482.00,144.60,48.36,409.70,,297.88,,,percent of total billed charges,,,94.24,,,fee schedule,,,235.22,,,percent of total billed charges,,,243.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,198.24,,,fee schedule,,,48.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",96.14,,,fee schedule,,,216.46,,,fee schedule,,,,,,,,,94.25,,,fee schedule,,,,,,,,,173.0,,,per diem,,,195.37,,,fee schedule,,,361.5,,,percent of total billed charges,,,94.24,,,fee schedule,,,48.36,,,fee schedule,,,96.12,,,fee schedule,,,204.0,,,per diem,,,94.25,,,fee schedule,,,361.5,,,percent of total billed charges,,,48.36,,,fee schedule,,,96.12,,,fee schedule,,,,,,,,,409.70,,,percent of total billed charges,,,221.72,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,94.25,,,fee schedule,,,,,,,,,229.0,,,per diem,,,94.24,,,fee schedule,,,,,,,,,94.24,,,fee schedule,,,,,,,,
Augmentative Treatment/Training - Speech Therapist,10391566,CDM,0440,RC,92609,CPT,269,EAPG,,,GN  ,outpatient,facility,,,482.00,144.60,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Augmentative Evaluation Additional 30 Minutes - S,10391567,CDM,0444,RC,92608,CPT,,,,,GN  ,outpatient,facility,,,247.00,74.10,12.59,260.0,,152.65,,,percent of total billed charges,,,44.37,,,fee schedule,,,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,93.34,,,fee schedule,,,12.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",45.26,,,fee schedule,,,101.90,,,fee schedule,,,,,,,,,44.37,,,fee schedule,,,,,,,,,173.0,,,per diem,,,91.98,,,fee schedule,,,185.25,,,percent of total billed charges,,,44.37,,,fee schedule,,,12.59,,,fee schedule,,,45.26,,,fee schedule,,,204.0,,,per diem,,,44.37,,,fee schedule,,,185.25,,,percent of total billed charges,,,12.59,,,fee schedule,,,45.26,,,fee schedule,,,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,44.37,,,fee schedule,,,,,,,,,229.0,,,per diem,,,44.37,,,fee schedule,,,,,,,,,44.37,,,fee schedule,,,,,,,,
Augmentative Evaluation Additional 30 Minutes - S,10391567,CDM,0444,RC,92608,CPT,272,EAPG,,,GN  ,outpatient,facility,,,247.00,74.10,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Augmentative Evaluation - Speech Therapist Complet,10391568,CDM,0444,RC,92607,CPT,,,,,GN  ,outpatient,facility,,,700.00,210.00,89.37,595.0,,432.60,,,percent of total billed charges,,,113.23,,,fee schedule,,,341.60,,,percent of total billed charges,,,353.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,238.19,,,fee schedule,,,89.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",115.54,,,fee schedule,,,260.15,,,fee schedule,,,,,,,,,113.27,,,fee schedule,,,,,,,,,173.0,,,per diem,,,234.74,,,fee schedule,,,525.0,,,percent of total billed charges,,,113.23,,,fee schedule,,,89.37,,,fee schedule,,,115.49,,,fee schedule,,,204.0,,,per diem,,,113.27,,,fee schedule,,,525.0,,,percent of total billed charges,,,89.37,,,fee schedule,,,115.49,,,fee schedule,,,,,,,,,595.0,,,percent of total billed charges,,,322.0,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,113.27,,,fee schedule,,,,,,,,,229.0,,,per diem,,,113.23,,,fee schedule,,,,,,,,,113.23,,,fee schedule,,,,,,,,
Augmentative Evaluation - Speech Therapist Complet,10391568,CDM,0444,RC,92607,CPT,272,EAPG,,,GN  ,outpatient,facility,,,700.00,210.00,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Speech Voice Analysis Eval - Speech Therapist Comp,10391569,CDM,0444,RC,92524,CPT,,,,,GN  ,outpatient,facility,,,274.00,82.20,87.19,267.51,,267.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,100.49,,,fee schedule,,,199.61,,,fee schedule,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,211.39,,,fee schedule,,,87.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",102.43,,,fee schedule,,,230.63,,,fee schedule,,,,,,,,,100.42,,,fee schedule,,,,,,,,,173.0,,,per diem,,,208.32,,,fee schedule,,,205.5,,,percent of total billed charges,,,100.49,,,fee schedule,,,87.19,,,fee schedule,,,102.5,,,fee schedule,,,204.0,,,per diem,,,100.42,,,fee schedule,,,205.5,,,percent of total billed charges,,,87.19,,,fee schedule,,,102.5,,,fee schedule,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,100.42,,,fee schedule,,,,,,,,,229.0,,,per diem,,,100.49,,,fee schedule,,,,,,,,,100.49,,,fee schedule,,,,,,,,
Speech Voice Analysis Eval - Speech Therapist Comp,10391569,CDM,0444,RC,92524,CPT,272,EAPG,,,GN  ,outpatient,facility,,,274.00,82.20,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Speech Lang Comp/Exp Eval - Speech Therapist Compl,10391570,CDM,0444,RC,92523,CPT,,,,,GN  ,outpatient,facility,,,469.00,140.70,173.0,482.04,,469.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,209.99,,,fee schedule,,,419.17,,,fee schedule,,,236.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,441.74,,,fee schedule,,,175.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",214.08,,,fee schedule,,,482.04,,,fee schedule,,,,,,,,,209.88,,,fee schedule,,,,,,,,,173.0,,,per diem,,,435.34,,,fee schedule,,,351.75,,,percent of total billed charges,,,209.99,,,fee schedule,,,175.08,,,fee schedule,,,214.19,,,fee schedule,,,204.0,,,per diem,,,209.88,,,fee schedule,,,351.75,,,percent of total billed charges,,,175.08,,,fee schedule,,,214.19,,,fee schedule,,,,,,,,,398.65,,,percent of total billed charges,,,215.74,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,209.88,,,fee schedule,,,,,,,,,229.0,,,per diem,,,209.99,,,fee schedule,,,,,,,,,209.99,,,fee schedule,,,,,,,,
Speech Lang Comp/Exp Eval - Speech Therapist Compl,10391570,CDM,0444,RC,92523,CPT,272,EAPG,,,GN  ,outpatient,facility,,,469.00,140.70,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Speech Sound Prod Eval - Speech Therapist Complete,10391571,CDM,0444,RC,92522,CPT,,,,,GN  ,outpatient,facility,,,227.00,68.10,84.55,260.0,,227.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,102.09,,,fee schedule,,,206.46,,,fee schedule,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,214.76,,,fee schedule,,,84.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,173.0,,,per diem,,,211.65,,,fee schedule,,,170.25,,,percent of total billed charges,,,102.09,,,fee schedule,,,84.55,,,fee schedule,,,104.13,,,fee schedule,,,204.0,,,per diem,,,101.97,,,fee schedule,,,170.25,,,percent of total billed charges,,,84.55,,,fee schedule,,,104.13,,,fee schedule,,,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,101.97,,,fee schedule,,,,,,,,,229.0,,,per diem,,,102.09,,,fee schedule,,,,,,,,,102.09,,,fee schedule,,,,,,,,
Speech Sound Prod Eval - Speech Therapist Complete,10391571,CDM,0444,RC,92522,CPT,272,EAPG,,,GN  ,outpatient,facility,,,227.00,68.10,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Speech Fluency Eval - Speech Therapist Completed,10391572,CDM,0444,RC,92521,CPT,,,,,GN  ,outpatient,facility,,,315.00,94.50,103.73,315.0,,315.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,122.88,,,fee schedule,,,241.39,,,fee schedule,,,158.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,258.5,,,fee schedule,,,103.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",125.32,,,fee schedule,,,282.18,,,fee schedule,,,,,,,,,122.86,,,fee schedule,,,,,,,,,173.0,,,per diem,,,254.76,,,fee schedule,,,236.25,,,percent of total billed charges,,,122.88,,,fee schedule,,,103.73,,,fee schedule,,,125.34,,,fee schedule,,,204.0,,,per diem,,,122.86,,,fee schedule,,,236.25,,,percent of total billed charges,,,103.73,,,fee schedule,,,125.34,,,fee schedule,,,,,,,,,267.75,,,percent of total billed charges,,,144.90,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,122.86,,,fee schedule,,,,,,,,,229.0,,,per diem,,,122.88,,,fee schedule,,,,,,,,,122.88,,,fee schedule,,,,,,,,
Speech Fluency Eval - Speech Therapist Completed,10391572,CDM,0444,RC,92521,CPT,272,EAPG,,,GN  ,outpatient,facility,,,315.00,94.50,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Speech Therapy Treatment - Speech Therapist Comple,10391573,CDM,0440,RC,92507,CPT,,,,,GN  ,outpatient,facility,,,359.00,107.70,70.56,305.15,,238.16,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,70.58,,,fee schedule,,,177.71,,,fee schedule,,,181.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,148.48,,,fee schedule,,,76.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",71.97,,,fee schedule,,,162.06,,,fee schedule,,,,,,,,,70.56,,,fee schedule,,,,,,,,,173.0,,,per diem,,,146.33,,,fee schedule,,,269.25,,,percent of total billed charges,,,70.58,,,fee schedule,,,76.38,,,fee schedule,,,71.99,,,fee schedule,,,204.0,,,per diem,,,70.56,,,fee schedule,,,269.25,,,percent of total billed charges,,,76.38,,,fee schedule,,,71.99,,,fee schedule,,,,,,,,,305.15,,,percent of total billed charges,,,165.14,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,70.56,,,fee schedule,,,,,,,,,229.0,,,per diem,,,70.58,,,fee schedule,,,,,,,,,70.58,,,fee schedule,,,,,,,,
Speech Therapy Treatment - Speech Therapist Comple,10391573,CDM,0440,RC,92507,CPT,272,EAPG,,,GN  ,outpatient,facility,,,359.00,107.70,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Adj tissue transfer eyelids nose ears and/or li,10393539,CDM,0450,RC,14060,CPT,,,,,,outpatient,facility,,,4226.00,1267.80,774.0,3592.10,,2611.67,,,percent of total billed charges,,,,,,,,,2062.29,,,percent of total billed charges,,,2131.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3169.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3592.10,,,percent of total billed charges,,,1943.96,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Adj tissue transfer eyelids nose ears and/or li,10393539,CDM,0450,RC,14060,CPT,05054,APC,,,,outpatient,facility,,,4226.00,1267.80,841.28,4028.88,,,,,,,,1754.17,,,fee schedule,,,,,,,,,,,,,,,3690.17,,,fee schedule,,,841.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1789.25,,,fee schedule,,,4028.88,,,fee schedule,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,,,,,,,3636.69,,,fee schedule,,,,,,,,,1754.17,,,fee schedule,,,841.28,,,fee schedule,,,1789.25,,,fee schedule,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,841.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1789.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,,,,,,,1754.17,,,fee schedule,,,,,,,,,1771.64,,,fee schedule,,,,,,,,
Adj tissue transfer eyelids nose ears and/or li,10393539,CDM,0450,RC,14060,CPT,56,EAPG,,,,outpatient,facility,,,4226.00,1267.80,2726.14,4906.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4906.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4170.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2824.78,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2726.14,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2998.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BEARING HUM SHOULDER 40MM,10397219,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING HUM SHOULDER 40MM,10397219,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SRV FEE BIO DBM BOAT SHT 10CM,10397222,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,3714.00,1114.20,1441.03,3156.90,,,,,,,,,,,,,,,,,,,,1441.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2785.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1857.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3156.90,,,percent of total billed charges,,,1671.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SRV FEE BIO DBM BOAT SHT 10CM,10397222,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,3714.00,1114.20,1578.45,3156.90,,,,,,,,,,,,,service not payable,,,,,,,1873.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1578.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2785.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1857.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2785.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3156.90,,,percent of total billed charges,,,1708.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SRV FEE BIO DBM BOAT SHT 10CM,10397222,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,3714.00,1114.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 11X12X25MM,10397223,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,6006.00,1801.80,2330.33,5105.10,,2942.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2522.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2330.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2552.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4504.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3003.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5105.10,,,percent of total billed charges,,,2702.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK AVS 4D 11X12X25MM,10397223,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,6006.00,1801.80,2522.52,5105.10,,2942.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2522.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3029.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2552.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4504.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3003.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4504.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5105.10,,,percent of total billed charges,,,2762.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SHT BLADE 7.5X50MM,10397224,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3856.00,1156.80,1496.13,3277.60,,,,,,,,,,,,,,,,,,,,1496.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.60,,,percent of total billed charges,,,1735.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SHT BLADE 7.5X50MM,10397224,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3856.00,1156.80,1638.8,3277.60,,,,,,,,,,,,,service not payable,,,,,,,1944.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3277.60,,,percent of total billed charges,,,1773.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LNG BLADE 7.5X50MM,10397225,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3856.00,1156.80,1496.13,3277.60,,,,,,,,,,,,,,,,,,,,1496.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.60,,,percent of total billed charges,,,1735.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LNG BLADE 7.5X50MM,10397225,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3856.00,1156.80,1638.8,3277.60,,,,,,,,,,,,,service not payable,,,,,,,1944.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3277.60,,,percent of total billed charges,,,1773.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD ES2 TITANIUM HEX 5.5X45MM,10397226,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1874.00,562.20,727.11,1592.90,,,,,,,,,,,,,,,,,,,,727.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1405.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,937.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1592.90,,,percent of total billed charges,,,843.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD ES2 TITANIUM HEX 5.5X45MM,10397226,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1874.00,562.20,796.45,1592.90,,,,,,,,,,,,,service not payable,,,,,,,945.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,796.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1405.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,937.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1405.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1592.90,,,percent of total billed charges,,,862.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 9.5,10397227,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 9.5,10397227,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT FEMORAL SHAFT 21CM,10397228,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4984.00,1495.20,1933.79,4236.40,,,,,,,,,,,,,,,,,,,,1933.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2118.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4236.40,,,percent of total billed charges,,,2242.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT FEMORAL SHAFT 21CM,10397228,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4984.00,1495.20,2118.20,4236.40,,,,,,,,,,,,,service not payable,,,,,,,2513.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2118.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4236.40,,,percent of total billed charges,,,2292.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT LEAD TINED W/PERCUTANEOUS X_2201 X_AXONICS MOD,10397229,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,10740.00,3222.00,4167.12,9129.0,,5262.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4510.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4167.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4564.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8055.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5370.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9129.0,,,percent of total billed charges,,,4833.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT LEAD TINED W/PERCUTANEOUS X_2201 X_AXONICS MOD,10397229,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,10740.00,3222.00,4510.80,9129.0,,5262.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4510.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5417.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4564.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8055.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5370.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8055.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9129.0,,,percent of total billed charges,,,4940.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM LONG 10X100MM,10397231,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1606.00,481.80,623.13,1365.10,,,,,,,,,,,,,,,,,,,,623.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.10,,,percent of total billed charges,,,722.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM LONG 10X100MM,10397231,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1606.00,481.80,682.55,1365.10,,,,,,,,,,,,,service not payable,,,,,,,810.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1365.10,,,percent of total billed charges,,,738.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT GNS II CON SZ3-4 11MM,10397234,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT GNS II CON SZ3-4 11MM,10397234,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP STANDARD JAW DISP,10397236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8689.00,2606.70,3371.33,7385.65,,4257.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3649.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3371.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3692.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4344.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7385.65,,,percent of total billed charges,,,3910.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP STANDARD JAW DISP,10397236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8689.00,2606.70,3649.38,7385.65,,4257.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3649.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4382.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3692.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6516.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4344.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6516.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7385.65,,,percent of total billed charges,,,3996.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY HUMERAL MINI 40MM  6MM,10397238,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY HUMERAL MINI 40MM  6MM,10397238,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SS ST NS HEX 2.7X22,10397239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,139.00,41.70,53.93,118.15,,,,,,,,,,,,,,,,,,,,53.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,104.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.15,,,percent of total billed charges,,,62.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SS ST NS HEX 2.7X22,10397239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,139.00,41.70,59.07,118.15,,,,,,,,,,,,,service not payable,,,,,,,70.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,104.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,69.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,104.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,118.15,,,percent of total billed charges,,,63.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 3CM TP 0.035INX260CM,10397240,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,91.46,,,percent of total billed charges,,,,,,,,service not payable,72.22,,,percent of total billed charges,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,96.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,96.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NLK HEXALOBE 2.7X26MM,10397241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,427.00,128.10,165.68,362.95,,,,,,,,,,,,,,,,,,,,165.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.95,,,percent of total billed charges,,,192.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NLK HEXALOBE 2.7X26MM,10397241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,427.00,128.10,181.47,362.95,,,,,,,,,,,,,service not payable,,,,,,,215.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,181.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,320.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,213.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,320.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,362.95,,,percent of total billed charges,,,196.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X55MM X_222855 X_SMITH NEPHEW,10397242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X55MM X_222855 X_SMITH NEPHEW,10397242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER XRAY CT MR GYNO X_101065-02 X_ELEKTA INC,10397244,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,6077.00,1823.10,2582.72,5165.45,,3755.59,,,percent of total billed charges,,,,,,,,service not payable,2965.58,,,percent of total billed charges,,,3065.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2582.72,,,percent of total billed charges,,,,,,,,,4557.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3038.5,,,percent of total billed charges,,,,,,,,service not payable,4557.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5165.45,,,percent of total billed charges,,,2795.42,,,percent of total billed charges,,,,,,,,,3950.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3950.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE 4-Y 1.28X559MM,10397245,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2475.00,742.50,1051.88,2103.75,,1529.55,,,percent of total billed charges,,,,,,,,service not payable,1207.8,,,percent of total billed charges,,,1248.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1051.88,,,percent of total billed charges,,,,,,,,,1856.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1237.5,,,percent of total billed charges,,,,,,,,service not payable,1856.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2103.75,,,percent of total billed charges,,,1138.5,,,percent of total billed charges,,,,,,,,,1608.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1608.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB HIP G7 SZ G 40MM,10401316,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB HIP G7 SZ G 40MM,10401316,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE HIP FEM TAPERED 3MM,10401317,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1312.00,393.60,509.06,1115.2,,,,,,,,,,,,,,,,,,,,509.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.2,,,percent of total billed charges,,,590.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE HIP FEM TAPERED 3MM,10401317,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1312.00,393.60,557.60,1115.2,,,,,,,,,,,,,service not payable,,,,,,,661.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,557.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,984.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,984.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1115.2,,,percent of total billed charges,,,603.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DILAT U35 4X60X130,10401318,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,449.00,134.70,190.82,381.65,,277.48,,,percent of total billed charges,,,,,,,,service not payable,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,190.82,,,percent of total billed charges,,,,,,,,,336.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,224.5,,,percent of total billed charges,,,,,,,,service not payable,336.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,291.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Removal Fecal Impaction or Foreign Body from R,10403392,CDM,0750,RC,45915,CPT,,,,,,outpatient,facility,,,2943.00,882.90,1353.78,3044.0,,2943.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1484.45,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,2207.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,2207.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.55,,,percent of total billed charges,,,1353.78,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Removal Fecal Impaction or Foreign Body from R,10403392,CDM,0750,RC,45915,CPT,05312,APC,,,,outpatient,facility,,,2943.00,882.90,1084.55,2596.92,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,2378.60,,,fee schedule,,,1084.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1153.3,,,fee schedule,,,2596.92,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,2344.12,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,1084.55,,,fee schedule,,,1153.3,,,fee schedule,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,1084.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1153.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,,,,,,,1130.69,,,fee schedule,,,,,,,,,1141.95,,,fee schedule,,,,,,,,
END-Removal Fecal Impaction or Foreign Body from R,10403392,CDM,0750,RC,45915,CPT,141,EAPG,,,,outpatient,facility,,,2943.00,882.90,2092.24,5987.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5987.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5089.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3000.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3300.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GP ID,10403568,CDM,0300,RC,87077,CPT,,,,,,outpatient,facility,,,51.00,15.30,7.68,43.35,,34.35,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.92,,,fee schedule,,,25.63,,,fee schedule,,,16.85,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,16.73,,,fee schedule,,,7.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.08,,,fee schedule,,,18.26,,,fee schedule,,,,,,,,,7.92,,,fee schedule,,,,,,,,,10.54,,,fee schedule,,,16.48,,,fee schedule,,,38.25,,,percent of total billed charges,,,7.92,,,fee schedule,,,7.68,,,fee schedule,,,8.08,,,fee schedule,,,12.39,,,fee schedule,,,7.92,,,fee schedule,,,38.25,,,percent of total billed charges,,,,,,,,,8.08,,,fee schedule,,,,,,,,,43.35,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,8.89,,,fee schedule,,,7.92,,,fee schedule,,,,,,,,,7.84,,,fee schedule,,,7.92,,,fee schedule,,,,,,,,,8.0,,,fee schedule,,,,,,,,
GP ID,10403568,CDM,0300,RC,87077,CPT,396,EAPG,,,,outpatient,facility,,,51.00,15.30,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT TIBIAL SZ4 13MM,10403766,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ4 13MM,10403766,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL LPS 12X125MM,10403767,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15835.00,4750.50,6143.98,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6143.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13459.75,,,percent of total billed charges,,,7125.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL LPS 12X125MM,10403767,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15835.00,4750.50,6650.70,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7987.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13459.75,,,percent of total billed charges,,,7284.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE REV FEM 35MM,10403768,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11512.00,3453.60,4466.66,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4466.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9785.20,,,percent of total billed charges,,,5180.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE REV FEM 35MM,10403768,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11512.00,3453.60,4835.04,9785.20,,5640.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4835.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5806.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4892.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8634.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5756.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8634.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9785.20,,,percent of total billed charges,,,5295.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGEMNT REV FEM POST SZ7 8MM,10403769,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8656.00,2596.80,3358.53,7357.60,,4241.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3635.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3358.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6492.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4328.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7357.60,,,percent of total billed charges,,,3895.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGEMNT REV FEM POST SZ7 8MM,10403769,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8656.00,2596.80,3635.52,7357.60,,4241.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3635.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4366.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6492.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4328.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6492.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7357.60,,,percent of total billed charges,,,3981.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REV PLATFORM SZ7 20MM,10403770,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV PLATFORM SZ7 20MM,10403770,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM REV 18X60MM,10403771,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REV 18X60MM,10403771,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL SZ7 19MM,10403772,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7535.00,2260.50,2923.58,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2923.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6404.75,,,percent of total billed charges,,,3390.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL SZ7 19MM,10403772,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7535.00,2260.50,3164.70,6404.75,,3692.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3164.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3800.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3202.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5651.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3767.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5651.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6404.75,,,percent of total billed charges,,,3466.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR ICONIX 2.3MM 2,10403773,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2546.00,763.80,987.85,2164.10,,,,,,,,,,,,,,,,,,,,987.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1082.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1909.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2164.10,,,percent of total billed charges,,,1145.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR ICONIX 2.3MM 2,10403773,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2546.00,763.80,1082.05,2164.10,,,,,,,,,,,,,service not payable,,,,,,,1284.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1082.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1909.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1909.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2164.10,,,percent of total billed charges,,,1171.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST SM ROUND HP 535ML,10403776,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4027.00,1208.10,1562.48,3422.95,,,,,,,,,,,,,,,,,,,,1562.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3422.95,,,percent of total billed charges,,,1812.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST SM ROUND HP 535ML,10403776,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4027.00,1208.10,1711.47,3422.95,,,,,,,,,,,,,service not payable,,,,,,,2031.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3422.95,,,percent of total billed charges,,,1852.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST SM ROUND HP 560ML,10403777,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4027.00,1208.10,1562.48,3422.95,,,,,,,,,,,,,,,,,,,,1562.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3422.95,,,percent of total billed charges,,,1812.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST SM ROUND HP 560ML,10403777,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4027.00,1208.10,1711.47,3422.95,,,,,,,,,,,,,service not payable,,,,,,,2031.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3422.95,,,percent of total billed charges,,,1852.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST XSMOOTH ROUND 595ML,10403778,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4027.00,1208.10,1562.48,3422.95,,,,,,,,,,,,,,,,,,,,1562.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3422.95,,,percent of total billed charges,,,1812.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST XSMOOTH ROUND 595ML,10403778,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4027.00,1208.10,1711.47,3422.95,,,,,,,,,,,,,service not payable,,,,,,,2031.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3422.95,,,percent of total billed charges,,,1852.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST SM RND EH 535ML,10403779,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST SM RND EH 535ML,10403779,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST SM RND EH 560ML,10403780,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST SM RND EH 560ML,10403780,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BREAST SM RND EH 595ML,10403781,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BREAST SM RND EH 595ML,10403781,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REV PLATFORM SZ7 22MM,10403782,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV PLATFORM SZ7 22MM,10403782,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE MEND 6CM X 10CM,10403783,CDM,0278,RC,Q4122,HCPCS,,,,,,inpatient,facility,,,11523.00,3456.90,4470.92,9794.55,,5646.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4839.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4470.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4897.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8642.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5761.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9794.55,,,percent of total billed charges,,,5185.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE MEND 6CM X 10CM,10403783,CDM,0278,RC,Q4122,HCPCS,,,,,,outpatient,facility,,,11523.00,3456.90,4839.66,9794.55,,5646.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4839.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5812.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4897.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8642.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5761.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8642.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9794.55,,,percent of total billed charges,,,5300.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE MEND 6CM X 10CM,10403783,CDM,0278,RC,Q4122,HCPCS,2010,EAPG,,,,outpatient,facility,,,11523.00,3456.90,110.0,110.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,110.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Acid Fast Fluorescent,10404,CDM,0300,RC,87206,CPT,,,,,,outpatient,facility,,,64.00,19.20,5.12,54.40,,22.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.28,,,fee schedule,,,17.08,,,fee schedule,,,11.24,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.16,,,fee schedule,,,5.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.39,,,fee schedule,,,12.18,,,fee schedule,,,,,,,,,5.28,,,fee schedule,,,,,,,,,6.73,,,fee schedule,,,11.0,,,fee schedule,,,48.0,,,percent of total billed charges,,,5.28,,,fee schedule,,,5.12,,,fee schedule,,,5.39,,,fee schedule,,,7.92,,,fee schedule,,,5.28,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,5.39,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,5.93,,,fee schedule,,,5.28,,,fee schedule,,,,,,,,,5.23,,,fee schedule,,,5.28,,,fee schedule,,,,,,,,,5.33,,,fee schedule,,,,,,,,
Acid Fast Fluorescent,10404,CDM,0300,RC,87206,CPT,396,EAPG,,,,outpatient,facility,,,64.00,19.20,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM HUMERAL STD SZ7B 90MM,10404332,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14965.00,4489.50,5806.42,12720.25,,7332.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6285.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5806.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6360.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11223.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7482.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12720.25,,,percent of total billed charges,,,6734.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL STD SZ7B 90MM,10404332,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14965.00,4489.50,6285.30,12720.25,,7332.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6285.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7548.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6360.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11223.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7482.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11223.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12720.25,,,percent of total billed charges,,,6883.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STD 44X21MM,10404333,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STD 44X21MM,10404333,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ2 13MM,10404334,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ2 13MM,10404334,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM ATTUNE CEM SZ8 L,10404339,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM ATTUNE CEM SZ8 L,10404339,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT CR RP SZ8 22MM,10404340,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT CR RP SZ8 22MM,10404340,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT POS FEM REV SZ 8 8MM,10404341,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT POS FEM REV SZ 8 8MM,10404341,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB ROTATING CEM SZ7,10404342,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17663.00,5298.90,6853.24,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6853.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15013.55,,,percent of total billed charges,,,7948.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB ROTATING CEM SZ7,10404342,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17663.00,5298.90,7418.46,15013.55,,8654.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7418.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8909.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7506.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13247.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8831.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13247.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15013.55,,,percent of total billed charges,,,8124.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7X80MMX130CM,10404346,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 8X80MMX80CM,10404347,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2438.65,4877.30,,3546.08,,,percent of total billed charges,,,,,,,,service not payable,2800.14,,,percent of total billed charges,,,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2869.0,,,percent of total billed charges,,,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT NAIL TI R1/5 LT 11X380MM,10404348,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT NAIL TI R1/5 LT 11X380MM,10404348,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT REV FEM DIST SZ7 8MM,10404349,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT REV FEM DIST SZ7 8MM,10404349,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY HUMERAL MINI 40MM  3MM,10404350,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY HUMERAL MINI 40MM  3MM,10404350,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 5F 0.035INX4X30MMX135CM,10404351,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,522.75,1045.5,,760.14,,,percent of total billed charges,,,,,,,,service not payable,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,922.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2 LEVEL 36MM OZARK,10404352,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2907.00,872.10,1127.92,2470.95,,,,,,,,,,,,,,,,,,,,1127.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2470.95,,,percent of total billed charges,,,1308.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2 LEVEL 36MM OZARK,10404352,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2907.00,872.10,1235.47,2470.95,,,,,,,,,,,,,service not payable,,,,,,,1466.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1235.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2180.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2470.95,,,percent of total billed charges,,,1337.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Open Perc Placement Stent Upper Extrem w/angioplas,10404506,CDM,0481,RC,37236,CPT,,,,,,outpatient,facility,,,29722.00,8916.60,4917.20,25263.70,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,14991.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,22291.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,22291.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25263.70,,,percent of total billed charges,,,13672.12,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Open Perc Placement Stent Upper Extrem w/angioplas,10404506,CDM,0481,RC,37236,CPT,05193,APC,,,,outpatient,facility,,,29722.00,8916.60,10431.35,24977.68,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22877.78,,,fee schedule,,,10431.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11081.84,,,fee schedule,,,24977.68,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22546.22,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,10431.35,,,fee schedule,,,11081.84,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10431.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",11081.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10972.86,,,fee schedule,,,,,,,,
Open Perc Placement Stent Upper Extrem w/angioplas,10404506,CDM,0481,RC,37236,CPT,85,EAPG,,,,outpatient,facility,,,29722.00,8916.60,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Needle insertion(s) w/o injection(s) 1 or 2 muscl,10404589,CDM,0420,RC,20560,CPT,,,,,GP  ,outpatient,facility,,,274.00,82.20,126.04,260.0,,169.33,,,percent of total billed charges,,,,,,,,,133.71,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,204.0,,,per diem,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Needle insertion(s) w/o injection(s) 1 or 2 muscl,10404589,CDM,0420,RC,20560,CPT,05731,APC,,,GP  ,outpatient,facility,,,274.00,82.20,23.49,53.95,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,49.41,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,53.95,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,48.69,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.72,,,fee schedule,,,,,,,,
Needle insertion(s) w/o injection(s) 1 or 2 muscl,10404589,CDM,0420,RC,20560,CPT,493,EAPG,,,GP  ,outpatient,facility,,,274.00,82.20,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Needle insertion(s) w/o injections(s) 3 or more m,10404590,CDM,0761,RC,20561,CPT,,,,,GP  ,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,137.0,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Needle insertion(s) w/o injections(s) 3 or more m,10404590,CDM,0761,RC,20561,CPT,05731,APC,,,GP  ,outpatient,facility,,,274.00,82.20,23.49,53.95,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,49.41,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,53.95,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,48.69,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.96,,,fee schedule,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,,,,,,,23.49,,,fee schedule,,,,,,,,,23.72,,,fee schedule,,,,,,,,
Needle insertion(s) w/o injections(s) 3 or more m,10404590,CDM,0761,RC,20561,CPT,493,EAPG,,,GP  ,outpatient,facility,,,274.00,82.20,52.89,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.89,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMIC 110,10404605,CDM,0300,RC,87186,CPT,,,,,,outpatient,facility,,,103.00,30.90,8.22,87.55,,36.75,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,8.48,,,fee schedule,,,27.42,,,fee schedule,,,18.04,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,17.91,,,fee schedule,,,8.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.65,,,fee schedule,,,19.55,,,fee schedule,,,,,,,,,8.48,,,fee schedule,,,,,,,,,10.96,,,fee schedule,,,17.65,,,fee schedule,,,77.25,,,percent of total billed charges,,,8.48,,,fee schedule,,,8.22,,,fee schedule,,,8.65,,,fee schedule,,,12.89,,,fee schedule,,,8.48,,,fee schedule,,,77.25,,,percent of total billed charges,,,,,,,,,8.65,,,fee schedule,,,,,,,,,87.55,,,percent of total billed charges,,,47.38,,,percent of total billed charges,,,,,,,,,9.52,,,fee schedule,,,8.48,,,fee schedule,,,,,,,,,8.39,,,fee schedule,,,8.48,,,fee schedule,,,,,,,,,8.57,,,fee schedule,,,,,,,,
PMIC 110,10404605,CDM,0300,RC,87186,CPT,396,EAPG,,,,outpatient,facility,,,103.00,30.90,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NMIC 306,10404606,CDM,0300,RC,87186,CPT,,,,,,outpatient,facility,,,103.00,30.90,8.22,87.55,,36.75,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,8.48,,,fee schedule,,,27.42,,,fee schedule,,,18.04,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,17.91,,,fee schedule,,,8.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.65,,,fee schedule,,,19.55,,,fee schedule,,,,,,,,,8.48,,,fee schedule,,,,,,,,,10.96,,,fee schedule,,,17.65,,,fee schedule,,,77.25,,,percent of total billed charges,,,8.48,,,fee schedule,,,8.22,,,fee schedule,,,8.65,,,fee schedule,,,12.89,,,fee schedule,,,8.48,,,fee schedule,,,77.25,,,percent of total billed charges,,,,,,,,,8.65,,,fee schedule,,,,,,,,,87.55,,,percent of total billed charges,,,47.38,,,percent of total billed charges,,,,,,,,,9.52,,,fee schedule,,,8.48,,,fee schedule,,,,,,,,,8.39,,,fee schedule,,,8.48,,,fee schedule,,,,,,,,,8.57,,,fee schedule,,,,,,,,
NMIC 306,10404606,CDM,0300,RC,87186,CPT,396,EAPG,,,,outpatient,facility,,,103.00,30.90,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
H. Influenza FH,10405243,CDM,0300,RC,87184,CPT,,,,,,outpatient,facility,,,86.00,25.80,7.11,73.10,,29.32,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.33,,,fee schedule,,,21.88,,,fee schedule,,,15.6,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,15.48,,,fee schedule,,,7.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.48,,,fee schedule,,,16.90,,,fee schedule,,,,,,,,,7.33,,,fee schedule,,,,,,,,,9.69,,,fee schedule,,,15.26,,,fee schedule,,,64.5,,,percent of total billed charges,,,7.33,,,fee schedule,,,7.11,,,fee schedule,,,7.48,,,fee schedule,,,11.4,,,fee schedule,,,7.33,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,7.48,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,8.23,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.26,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.40,,,fee schedule,,,,,,,,
H. Influenza FH,10405243,CDM,0300,RC,87184,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT GRAFT VASC 23MM 14CM,10405255,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15303.00,4590.90,5937.56,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5937.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13007.55,,,percent of total billed charges,,,6886.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT VASC 23MM 14CM,10405255,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15303.00,4590.90,6427.26,13007.55,,7498.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6427.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7718.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6503.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11477.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7651.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11477.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13007.55,,,percent of total billed charges,,,7039.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN ATRICLIP 40MM FLEX,10405256,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN ATRICLIP 40MM FLEX,10405256,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BLUE LCKG 2.5X10MM,10405257,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,696.00,208.80,270.05,591.60,,,,,,,,,,,,,,,,,,,,270.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,522.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,348.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.60,,,percent of total billed charges,,,313.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BLUE LCKG 2.5X10MM,10405257,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,696.00,208.80,295.80,591.60,,,,,,,,,,,,,service not payable,,,,,,,351.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,295.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,522.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,348.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,522.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,591.60,,,percent of total billed charges,,,320.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW GOLD CRTX 2.5X22MM,10405258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,429.00,128.70,166.45,364.65,,,,,,,,,,,,,,,,,,,,166.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,321.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.65,,,percent of total billed charges,,,193.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW GOLD CRTX 2.5X22MM,10405258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,429.00,128.70,182.32,364.65,,,,,,,,,,,,,service not payable,,,,,,,216.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,182.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,321.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,321.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,364.65,,,percent of total billed charges,,,197.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW GOLD BONE CRTX 2.5X24MM,10405259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,429.00,128.70,166.45,364.65,,,,,,,,,,,,,,,,,,,,166.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,321.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.65,,,percent of total billed charges,,,193.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW GOLD BONE CRTX 2.5X24MM,10405259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,429.00,128.70,182.32,364.65,,,,,,,,,,,,,service not payable,,,,,,,216.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,182.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,321.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,321.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,364.65,,,percent of total billed charges,,,197.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK TI ST VAR ANG 5X3MM,10405260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1436.00,430.80,557.17,1220.60,,,,,,,,,,,,,,,,,,,,557.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,610.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1077.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,718.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1220.60,,,percent of total billed charges,,,646.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK TI ST VAR ANG 5X3MM,10405260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1436.00,430.80,610.30,1220.60,,,,,,,,,,,,,service not payable,,,,,,,724.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,610.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1077.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,718.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1077.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1220.60,,,percent of total billed charges,,,660.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAILS-FX TIB CANN PRX 345X10MM,10405261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6850.00,2055.00,2657.80,5822.5,,3356.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2877.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2657.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2911.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5822.5,,,percent of total billed charges,,,3082.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAILS-FX TIB CANN PRX 345X10MM,10405261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6850.00,2055.00,2877.0,5822.5,,3356.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2877.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3455.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2911.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5137.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5822.5,,,percent of total billed charges,,,3151.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ULNA MIDSHAFT 10H,10405262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3287.00,986.10,1275.36,2793.95,,,,,,,,,,,,,,,,,,,,1275.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1396.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2465.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1643.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2793.95,,,percent of total billed charges,,,1479.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ULNA MIDSHAFT 10H,10405262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3287.00,986.10,1396.97,2793.95,,,,,,,,,,,,,service not payable,,,,,,,1657.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1396.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2465.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1643.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2465.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2793.95,,,percent of total billed charges,,,1512.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS WATCHMAN ANTERIOR CRV 12F,10405263,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS WATCHMAN ANTERIOR CRV 12F,10405263,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM FRAC 12MM,10405264,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM FRAC 12MM,10405264,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Swallow Treatment - Speech Therapist Completed,10405385,CDM,0440,RC,92526,CPT,,,,,GN  ,outpatient,facility,,,359.00,107.70,70.60,305.15,,221.86,,,percent of total billed charges,,,77.67,,,fee schedule,,,175.19,,,percent of total billed charges,,,181.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,163.39,,,fee schedule,,,70.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",79.23,,,fee schedule,,,178.40,,,fee schedule,,,,,,,,,77.68,,,fee schedule,,,,,,,,,173.0,,,per diem,,,161.02,,,fee schedule,,,269.25,,,percent of total billed charges,,,77.67,,,fee schedule,,,70.60,,,fee schedule,,,79.22,,,fee schedule,,,204.0,,,per diem,,,77.68,,,fee schedule,,,269.25,,,percent of total billed charges,,,70.60,,,fee schedule,,,79.22,,,fee schedule,,,,,,,,,305.15,,,percent of total billed charges,,,165.14,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,77.68,,,fee schedule,,,,,,,,,229.0,,,per diem,,,77.67,,,fee schedule,,,,,,,,,77.67,,,fee schedule,,,,,,,,
Swallow Treatment - Speech Therapist Completed,10405385,CDM,0440,RC,92526,CPT,269,EAPG,,,GN  ,outpatient,facility,,,359.00,107.70,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Removal of implantable defibrillator pulse generat,10405655,CDM,0481,RC,33241,CPT,,,,,,outpatient,facility,,,5128.00,1538.40,2358.88,6509.0,,5128.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,2586.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,3846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,3846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4358.80,,,percent of total billed charges,,,2358.88,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal of implantable defibrillator pulse generat,10405655,CDM,0481,RC,33241,CPT,05221,APC,,,,outpatient,facility,,,5128.00,1538.40,3347.52,8015.59,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7341.71,,,fee schedule,,,3347.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3559.77,,,fee schedule,,,8015.59,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7235.31,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,3347.52,,,fee schedule,,,3559.77,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3347.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3559.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3524.73,,,fee schedule,,,,,,,,
Removal of implantable defibrillator pulse generat,10405655,CDM,0481,RC,33241,CPT,87,EAPG,,,,outpatient,facility,,,5128.00,1538.40,5128.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5128.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5128.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5128.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert or replace permanent implantable defib syst,10405661,CDM,0481,RC,33249,CPT,,,,,,outpatient,facility,,,61741.00,18522.30,8909.33,52479.85,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,31142.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,46305.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50947.0,,,case rate,,,,,,,,,46305.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52479.85,,,percent of total billed charges,,,28400.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Insert or replace permanent implantable defib syst,10405661,CDM,0481,RC,33249,CPT,05232,APC,,,,outpatient,facility,,,61741.00,18522.30,29491.09,70615.80,,,,,,,,30654.53,,,fee schedule,,,,,,,,,,,,,,,64679.08,,,fee schedule,,,29491.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",31267.62,,,fee schedule,,,70615.80,,,fee schedule,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,,,,,,,63741.70,,,fee schedule,,,,,,,,,30654.53,,,fee schedule,,,29491.09,,,fee schedule,,,31267.62,,,fee schedule,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,29491.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",31267.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,30960.74,,,fee schedule,,,,,,,,
Insert or replace permanent implantable defib syst,10405661,CDM,0481,RC,33249,CPT,97,EAPG,,,,outpatient,facility,,,61741.00,18522.30,32245.61,50588.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50588.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,42999.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42921.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,47214.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-Colostomy closure w/Resection and Anastomosis,10405664,CDM,0750,RC,44626,CPT,,,,,,outpatient,facility,,,5567.00,1670.10,1201.08,7856.0,,5567.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,2807.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,1201.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,4175.25,,,percent of total billed charges,,,,,,,,service not payable,1201.08,,,fee schedule,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,4175.25,,,percent of total billed charges,,,1201.08,,,fee schedule,,,,,,,,service not payable,,,,,,,4731.95,,,percent of total billed charges,,,2560.82,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Colostomy closure w/Resection and Anastomosis,10405664,CDM,0750,RC,44626,CPT,128,EAPG,,,,outpatient,facility,,,5567.00,1670.10,5553.15,14097.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14097.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,11982.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5553.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5553.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5553.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6883.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,7572.25,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
RHC w/transcatheter implant wireless pulmonary art,10405668,CDM,0481,RC,33289,CPT,,,,,,outpatient,facility,,,61358.00,18407.40,10719.0,52154.30,,13476.59,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,10719.0,,,case rate,,,30948.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,46018.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,50947.0,,,case rate,,,,,,,,,46018.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,52154.30,,,percent of total billed charges,,,28224.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RHC w/transcatheter implant wireless pulmonary art,10405668,CDM,0481,RC,33289,CPT,05200,APC,,,,outpatient,facility,,,61358.00,18407.40,27184.53,62613.55,,,,,,,,27184.53,,,fee schedule,,,,,,,,,,,,,,,57349.58,,,fee schedule,,,,,,,,,27728.22,,,fee schedule,,,62613.55,,,fee schedule,,,,,,,,,27184.53,,,fee schedule,,,,,,,,,,,,,,,56518.42,,,fee schedule,,,,,,,,,27184.53,,,fee schedule,,,,,,,,,27728.22,,,fee schedule,,,,,,,,,27184.53,,,fee schedule,,,,,,,,,,,,,,,27728.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27184.53,,,fee schedule,,,,,,,,,,,,,,,27184.53,,,fee schedule,,,,,,,,,27456.04,,,fee schedule,,,,,,,,
RHC w/transcatheter implant wireless pulmonary art,10405668,CDM,0481,RC,33289,CPT,97,EAPG,,,,outpatient,facility,,,61358.00,18407.40,32245.61,50588.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50588.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,42999.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42921.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,47214.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Endomyocardial biopsy,10405671,CDM,0481,RC,93505,CPT,,,,,,outpatient,facility,,,3444.00,1033.20,1584.24,10719.0,,3444.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA CCATH PROC]] $13,476.59  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,10719.0,,,case rate,,,1737.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,2583.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,2583.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2927.40,,,percent of total billed charges,,,1584.24,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Endomyocardial biopsy,10405671,CDM,0481,RC,93505,CPT,05183,APC,,,,outpatient,facility,,,3444.00,1033.20,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Endomyocardial biopsy,10405671,CDM,0481,RC,93505,CPT,84,EAPG,,,,outpatient,facility,,,3444.00,1033.20,3444.0,10199.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10199.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8669.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3444.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3444.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3444.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4067.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4474.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH METACROSS 7X40MM 135CM,10405690,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,624.00,187.20,265.20,530.40,,385.63,,,percent of total billed charges,,,,,,,,service not payable,304.51,,,percent of total billed charges,,,314.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,265.20,,,percent of total billed charges,,,,,,,,,468.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,312.0,,,percent of total billed charges,,,,,,,,service not payable,468.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,530.40,,,percent of total billed charges,,,287.04,,,percent of total billed charges,,,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,405.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VASC 0.035IN 80CM,10405701,CDM,0278,RC,C1769,HCPCS,,,,,,inpatient,facility,,,280.00,84.00,108.64,238.0,,,,,,,,,,,,,,,,,,,,108.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.0,,,percent of total billed charges,,,126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDEWIRE VASC 0.035IN 80CM,10405701,CDM,0278,RC,C1769,HCPCS,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,,,,,,,,,,,,service not payable,,,,,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE WHISPER LS 3X190CM,10405728,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE BMW UII 300CM,10405729,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE PILOT 150 190CM J,10405731,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,237.31,,,percent of total billed charges,,,,,,,,service not payable,187.39,,,percent of total billed charges,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,249.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DRAINAGE 8F 30CM,10405734,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,418.00,125.40,177.65,355.30,,258.32,,,percent of total billed charges,,,,,,,,service not payable,203.98,,,percent of total billed charges,,,210.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,209.0,,,percent of total billed charges,,,,,,,,service not payable,313.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,355.30,,,percent of total billed charges,,,192.28,,,percent of total billed charges,,,,,,,,,271.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,271.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7X39MM VASC VBX 135CM,10406237,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10845.00,3253.50,4207.86,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4207.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9218.25,,,percent of total billed charges,,,4880.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7X39MM VASC VBX 135CM,10406237,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10845.00,3253.50,4554.90,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5470.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9218.25,,,percent of total billed charges,,,4988.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 8X29MM VASC VBX 135CM,10406238,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10845.00,3253.50,4207.86,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4207.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9218.25,,,percent of total billed charges,,,4880.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 8X29MM VASC VBX 135CM,10406238,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10845.00,3253.50,4554.90,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5470.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9218.25,,,percent of total billed charges,,,4988.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 9X29MM VASC VBX 135CM,10406239,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10845.00,3253.50,4207.86,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4207.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9218.25,,,percent of total billed charges,,,4880.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 9X29MM VASC VBX 135CM,10406239,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10845.00,3253.50,4554.90,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5470.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9218.25,,,percent of total billed charges,,,4988.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 10X29MM VASC VBX 135CM,10406240,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10845.00,3253.50,4207.86,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4207.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9218.25,,,percent of total billed charges,,,4880.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 10X29MM VASC VBX 135CM,10406240,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10845.00,3253.50,4554.90,9218.25,,5314.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4554.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5470.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4609.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9218.25,,,percent of total billed charges,,,4988.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SOFTSILK 9.0X25MM,10406241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1125.00,337.50,436.5,956.25,,,,,,,,,,,,,,,,,,,,436.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,956.25,,,percent of total billed charges,,,506.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SOFTSILK 9.0X25MM,10406241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1125.00,337.50,478.12,956.25,,,,,,,,,,,,,service not payable,,,,,,,567.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,478.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,956.25,,,percent of total billed charges,,,517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SOFTSILK 8.0X25MM,10406242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1125.00,337.50,436.5,956.25,,,,,,,,,,,,,,,,,,,,436.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,956.25,,,percent of total billed charges,,,506.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SOFTSILK 8.0X25MM,10406242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1125.00,337.50,478.12,956.25,,,,,,,,,,,,,service not payable,,,,,,,567.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,478.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,956.25,,,percent of total billed charges,,,517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY FOLEY SRSTP W/U M 16F,10406355,CDM,0272,RC,A4315,HCPCS,,,,,,outpatient,facility,,,1380.00,414.00,586.5,1173.0,,852.84,,,percent of total billed charges,,,,,,,,service not payable,673.44,,,percent of total billed charges,,,696.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,586.5,,,percent of total billed charges,,,,,,,,,1035.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,690.0,,,percent of total billed charges,,,,,,,,service not payable,1035.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1173.0,,,percent of total billed charges,,,634.80,,,percent of total billed charges,,,,,,,,,897.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,897.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN ATRICLIP 35MM FLEX,10406356,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN ATRICLIP 35MM FLEX,10406356,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Intracardiac Catheter Ablation of ARRH,10406383,CDM,0481,RC,93655,CPT,,,,,,outpatient,facility,,,1201.00,360.30,552.46,2912.34,,1201.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,605.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,900.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,900.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1020.85,,,percent of total billed charges,,,552.46,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Intracardiac Catheter Ablation of ARRH,10406383,CDM,0481,RC,93655,CPT,82,EAPG,,,,outpatient,facility,,,1201.00,360.30,1201.0,28514.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27622.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23479.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1201.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1201.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1201.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25922.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,28514.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intracardiac EP 3D Mapping,10406394,CDM,0481,RC,93613,CPT,,,,,,outpatient,facility,,,2987.00,896.10,1106.0,5463.36,,2987.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,1506.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,2240.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,2240.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2538.95,,,percent of total billed charges,,,1374.02,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Intracardiac EP 3D Mapping,10406394,CDM,0481,RC,93613,CPT,96,EAPG,,,,outpatient,facility,,,2987.00,896.10,2987.0,18075.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18075.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,15364.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2987.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2987.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2987.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14048.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,15453.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tx Atrial Fib Pulm Ven Isol,10406397,CDM,0481,RC,93656,CPT,,,,,,outpatient,facility,,,36205.00,10861.50,8909.33,30774.25,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,18261.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,27153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,27153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30774.25,,,percent of total billed charges,,,16654.30,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tx Atrial Fib Pulm Ven Isol,10406397,CDM,0481,RC,93656,CPT,05213,APC,,,,outpatient,facility,,,36205.00,10861.50,22565.46,54032.53,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,49489.97,,,fee schedule,,,22565.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",23932.83,,,fee schedule,,,54032.53,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,48772.73,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,22565.46,,,fee schedule,,,23932.83,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,22565.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",23932.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,23697.85,,,fee schedule,,,,,,,,
Tx Atrial Fib Pulm Ven Isol,10406397,CDM,0481,RC,93656,CPT,82,EAPG,,,,outpatient,facility,,,36205.00,10861.50,23479.06,28514.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27622.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23479.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25922.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,28514.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insertion IA Balloon Assist Device,10406400,CDM,0481,RC,33967,CPT,,,,,,outpatient,facility,,,3912.00,1173.60,244.61,40166.0,,3912.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,244.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,32559.0,,,case rate,,,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,244.61,,,fee schedule,,,,,,,,,38305.0,,,case rate,,,,,,,,service not payable,2934.0,,,percent of total billed charges,,,244.61,,,fee schedule,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,service not payable,,,,,,,35346.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insertion IA Balloon Assist Device,10406400,CDM,0481,RC,33967,CPT,86,EAPG,,,,outpatient,facility,,,3912.00,1173.60,3912.0,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3912.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3912.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3912.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tx Missed AB completed surgically second trimester,10414869,CDM,0450,RC,59821,CPT,,,,,,outpatient,facility,,,6505.00,1951.50,774.0,5529.25,,4020.09,,,percent of total billed charges,,,,,,,,,3174.44,,,percent of total billed charges,,,3281.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4878.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4878.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5529.25,,,percent of total billed charges,,,2992.30,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tx Missed AB completed surgically second trimester,10414869,CDM,0450,RC,59821,CPT,05414,APC,,,,outpatient,facility,,,6505.00,1951.50,1462.31,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,1462.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,1462.31,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,1462.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Tx Missed AB completed surgically second trimester,10414869,CDM,0450,RC,59821,CPT,194,EAPG,,,,outpatient,facility,,,6505.00,1951.50,2515.77,5077.20,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5077.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4315.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2515.77,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2515.77,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2515.77,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2801.78,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3081.96,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Transferrin Profile - FH - Transferrin,10415336,CDM,0300,RC,84466,CPT,,,,,,outpatient,facility,,,79.00,23.70,12.12,67.15,,54.27,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.5,,,fee schedule,,,40.5,,,fee schedule,,,26.61,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,26.41,,,fee schedule,,,12.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.75,,,fee schedule,,,28.84,,,fee schedule,,,,,,,,,12.5,,,fee schedule,,,,,,,,,16.43,,,fee schedule,,,26.03,,,fee schedule,,,59.25,,,percent of total billed charges,,,12.5,,,fee schedule,,,12.12,,,fee schedule,,,12.75,,,fee schedule,,,19.32,,,fee schedule,,,12.5,,,fee schedule,,,59.25,,,percent of total billed charges,,,,,,,,,12.75,,,fee schedule,,,,,,,,,67.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,,,,,,,14.04,,,fee schedule,,,12.5,,,fee schedule,,,,,,,,,12.38,,,fee schedule,,,12.5,,,fee schedule,,,,,,,,,12.63,,,fee schedule,,,,,,,,
Transferrin Profile - FH - Transferrin,10415336,CDM,0300,RC,84466,CPT,400,EAPG,,,,outpatient,facility,,,79.00,23.70,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ROD 5.5X30MM,10430270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,536.00,160.80,207.97,455.60,,,,,,,,,,,,,,,,,,,,207.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.60,,,percent of total billed charges,,,241.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD 5.5X30MM,10430270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,536.00,160.80,227.80,455.60,,,,,,,,,,,,,service not payable,,,,,,,270.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,402.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,455.60,,,percent of total billed charges,,,246.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DYNANITE PIP BENT 14MM W/INSTR,10430271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DYNANITE PIP BENT 14MM W/INSTR,10430271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ5 RT,10430272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ5 RT,10430272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST SALINE 550ML,10430274,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST SALINE 550ML,10430274,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSF 295CC,10430275,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 295CC,10430275,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIATRAC 14 PTA 5X20MM 5F,10430277,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIATRAC 14 PTA 5X30X80,10430278,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH VIATRAC 14 PTA 5X40X80,10430279,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
"STEM FEM SOL ST 8X18MM""""",10430280,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,28328.00,8498.40,10991.26,24078.80,,13880.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11897.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10991.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12039.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24078.80,,,percent of total billed charges,,,12747.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"STEM FEM SOL ST 8X18MM""""",10430280,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,28328.00,8498.40,11897.76,24078.80,,13880.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11897.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14288.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12039.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24078.80,,,percent of total billed charges,,,13030.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 21.0D,10430281,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 21.0D,10430281,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 18.0,10430282,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 18.0,10430282,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER VASC 7F 23CM,10430283,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,259.00,77.70,110.08,220.15,,160.06,,,percent of total billed charges,,,,,,,,service not payable,126.39,,,percent of total billed charges,,,130.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,194.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,service not payable,194.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,220.15,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,,,,,,,168.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,168.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT BONE SURG TOBRA,10430466,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1365.00,409.50,529.62,1160.25,,,,,,,,,,,,,,,,,,,,529.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1023.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1160.25,,,percent of total billed charges,,,614.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT BONE SURG TOBRA,10430466,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1365.00,409.50,580.12,1160.25,,,,,,,,,,,,,service not payable,,,,,,,688.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1023.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1023.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1160.25,,,percent of total billed charges,,,627.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PIP BENT 16MM,10430476,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PIP BENT 16MM,10430476,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PIP BENT 12MM,10430477,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PIP BENT 12MM,10430477,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW REV CENTRAL 6.5X40MM,10430478,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW REV CENTRAL 6.5X40MM,10430478,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM LONG SZ 1B 88MM,10430646,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17460.00,5238.00,6774.48,14841.0,,8555.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7333.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6774.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13095.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8730.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14841.0,,,percent of total billed charges,,,7857.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM LONG SZ 1B 88MM,10430646,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17460.00,5238.00,7333.20,14841.0,,8555.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7333.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8806.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13095.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8730.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13095.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14841.0,,,percent of total billed charges,,,8031.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MODEL MANDIBLE CLASSIC,10430647,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7525.00,2257.50,2919.70,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2919.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6396.25,,,percent of total billed charges,,,3386.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MODEL MANDIBLE CLASSIC,10430647,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7525.00,2257.50,3160.5,6396.25,,3687.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3160.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3795.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3198.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5643.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5643.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6396.25,,,percent of total billed charges,,,3461.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BALN PTA 4X60MM 130CM,10430648,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BALLOON PTA 3X210MM,10430649,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,1452.3,,,percent of total billed charges,,,,,,,,service not payable,1146.8,,,percent of total billed charges,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 3DMAX RT 5X7IN,10430650,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1034.00,310.20,401.19,878.90,,,,,,,,,,,,,,,,,,,,401.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,775.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,517.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.90,,,percent of total billed charges,,,465.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 3DMAX RT 5X7IN,10430650,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1034.00,310.20,439.45,878.90,,,,,,,,,,,,,service not payable,,,,,,,521.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,775.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,517.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,775.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.90,,,percent of total billed charges,,,475.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT HAND BASED INLINE RT XS,10430654,CDM,0271,RC,A4570,HCPCS,,,,,,outpatient,facility,,,82.00,24.60,7.18,69.70,,50.68,,,percent of total billed charges,,,,,,,,service not payable,40.02,,,percent of total billed charges,,,41.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,41.0,,,fee schedule,,,7.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,41.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,34.85,,,percent of total billed charges,,,,,,,,,61.5,,,percent of total billed charges,,,,,,,,service not payable,7.18,,,fee schedule,,,,,,,,,41.0,,,percent of total billed charges,,,,,,,,service not payable,61.5,,,percent of total billed charges,,,7.18,,,fee schedule,,,36.90,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,,37.72,,,percent of total billed charges,,,,,,,,,53.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,53.30,,,percent of total billed charges,,,41.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SPLINT RADIAL ULNAR DEV RT SM,10430655,CDM,0271,RC,A4570,HCPCS,,,,,,outpatient,facility,,,292.00,87.60,7.18,248.20,,180.46,,,percent of total billed charges,,,,,,,,service not payable,142.5,,,percent of total billed charges,,,147.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,146.0,,,fee schedule,,,7.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,146.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,124.10,,,percent of total billed charges,,,,,,,,,219.0,,,percent of total billed charges,,,,,,,,service not payable,7.18,,,fee schedule,,,,,,,,,146.0,,,percent of total billed charges,,,,,,,,service not payable,219.0,,,percent of total billed charges,,,7.18,,,fee schedule,,,131.40,,,fee schedule,,,,,,,,,248.20,,,percent of total billed charges,,,134.32,,,percent of total billed charges,,,,,,,,,189.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,189.80,,,percent of total billed charges,,,146.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
JOINT FINGER SZ40,10430656,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3372.00,1011.60,1308.34,2866.20,,,,,,,,,,,,,,,,,,,,1308.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1433.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2529.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1686.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2866.20,,,percent of total billed charges,,,1517.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JOINT FINGER SZ40,10430656,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3372.00,1011.60,1433.10,2866.20,,,,,,,,,,,,,service not payable,,,,,,,1700.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1433.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2529.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1686.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2529.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2866.20,,,percent of total billed charges,,,1551.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert pacing lead and attach to existing pacemake,10430858,CDM,0481,RC,33224,CPT,,,,,,outpatient,facility,,,19985.00,5995.50,4917.20,28801.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,10080.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,14988.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,14988.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16987.25,,,percent of total billed charges,,,9193.10,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert pacing lead and attach to existing pacemake,10430858,CDM,0481,RC,33224,CPT,05223,APC,,,,outpatient,facility,,,19985.00,5995.50,9626.29,23049.94,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,21112.12,,,fee schedule,,,9626.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10229.20,,,fee schedule,,,23049.94,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,20806.14,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,9626.29,,,fee schedule,,,10229.20,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,9626.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",10229.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,10128.58,,,fee schedule,,,,,,,,
Insert pacing lead and attach to existing pacemake,10430858,CDM,0481,RC,33224,CPT,86,EAPG,,,,outpatient,facility,,,19985.00,5995.50,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Intracardiac Catheter Ablation AV Node,10430861,CDM,0481,RC,93650,CPT,,,,,,outpatient,facility,,,15190.00,4557.00,6987.40,12911.5,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,7661.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,11392.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,11392.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12911.5,,,percent of total billed charges,,,6987.40,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Intracardiac Catheter Ablation AV Node,10430861,CDM,0481,RC,93650,CPT,05212,APC,,,,outpatient,facility,,,15190.00,4557.00,6979.74,16712.84,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,15307.77,,,fee schedule,,,6979.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7422.27,,,fee schedule,,,16712.84,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,15085.92,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,6979.74,,,fee schedule,,,7422.27,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,6979.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",7422.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,7349.21,,,fee schedule,,,,,,,,
Intracardiac Catheter Ablation AV Node,10430861,CDM,0481,RC,93650,CPT,82,EAPG,,,,outpatient,facility,,,15190.00,4557.00,15190.0,28514.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27622.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23479.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15190.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15190.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15190.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25922.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,28514.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert Left Vent Pacing Lead,10430868,CDM,0481,RC,33225,CPT,,,,,,outpatient,facility,,,19985.00,5995.50,5463.36,28801.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,10080.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,24481.0,,,case rate,,,,,,,,,14988.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,service not payable,14988.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16987.25,,,percent of total billed charges,,,9193.10,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,service not payable,,,,,,,23568.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert Left Vent Pacing Lead,10430868,CDM,0481,RC,33225,CPT,86,EAPG,,,,outpatient,facility,,,19985.00,5995.50,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Selective catheter placement venous 2nd order,10435408,CDM,0481,RC,36012,CPT,,,,,,outpatient,facility,,,1496.00,448.80,688.16,2912.34,,1496.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,754.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,1122.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,1122.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1271.60,,,percent of total billed charges,,,688.16,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Selective catheter placement venous 2nd order,10435408,CDM,0481,RC,36012,CPT,423,EAPG,,,,outpatient,facility,,,1496.00,448.80,994.94,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Replace/Remove Card/Defib Generator multiple lead,10435409,CDM,0481,RC,33264,CPT,,,,,,outpatient,facility,,,52178.00,15653.40,4917.20,50947.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,26318.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,39133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50947.0,,,case rate,,,,,,,,,39133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44351.30,,,percent of total billed charges,,,24001.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Replace/Remove Card/Defib Generator multiple lead,10435409,CDM,0481,RC,33264,CPT,05232,APC,,,,outpatient,facility,,,52178.00,15653.40,29491.09,70615.80,,,,,,,,30654.53,,,fee schedule,,,,,,,,,,,,,,,64679.08,,,fee schedule,,,29491.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",31267.62,,,fee schedule,,,70615.80,,,fee schedule,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,,,,,,,63741.70,,,fee schedule,,,,,,,,,30654.53,,,fee schedule,,,29491.09,,,fee schedule,,,31267.62,,,fee schedule,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,29491.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",31267.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,,,,,,,30654.53,,,fee schedule,,,,,,,,,30960.74,,,fee schedule,,,,,,,,
Replace/Remove Card/Defib Generator multiple lead,10435409,CDM,0481,RC,33264,CPT,97,EAPG,,,,outpatient,facility,,,52178.00,15653.40,32245.61,50588.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50588.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,42999.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42921.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,47214.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SIZER VOICE BLOMSNGR 20F X_BE2036 X_359625,10435509,CDM,0274,RC,L8507,HCPCS,,,,,,inpatient,facility,,,610.00,183.00,236.68,518.5,,,,,,,,,,,,,,,,,,,,236.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,457.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,305.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,518.5,,,percent of total billed charges,,,274.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER VOICE BLOMSNGR 20F X_BE2036 X_359625,10435509,CDM,0274,RC,L8507,HCPCS,,,,,,outpatient,facility,,,610.00,183.00,34.58,518.5,,,,,,,,49.53,,,fee schedule,,,,,,,,,307.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,104.2,,,fee schedule,,,34.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",50.52,,,fee schedule,,,113.77,,,fee schedule,,,,,,,,,49.53,,,fee schedule,,,,,,,,,259.25,,,percent of total billed charges,,Paid in addition to outpatient services ,102.69,,,fee schedule,,,457.5,,,percent of total billed charges,,,49.53,,,fee schedule,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,305.0,,,percent of total billed charges,,Paid in addition to outpatient services ,49.53,,,fee schedule,,,457.5,,,percent of total billed charges,,,34.58,,,fee schedule,,,50.52,,,fee schedule,,,,,,,,,518.5,,,percent of total billed charges,,,280.60,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,,,,,,,49.53,,,fee schedule,,,,,,,,,50.03,,,fee schedule,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 21.5,10435583,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 21.5,10435583,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ATTUNE CRS FEMORAL RT SZ 7 CEM,10435584,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23505.00,7051.50,9119.94,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9119.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19979.25,,,percent of total billed charges,,,10577.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATTUNE CRS FEMORAL RT SZ 7 CEM,10435584,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23505.00,7051.50,9872.10,19979.25,,11517.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9872.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11855.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9989.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17628.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11752.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17628.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19979.25,,,percent of total billed charges,,,10812.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL RP CEM SZ5,10435585,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16864.00,5059.20,6543.23,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6543.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14334.4,,,percent of total billed charges,,,7588.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL RP CEM SZ5,10435585,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16864.00,5059.20,7082.88,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8506.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14334.4,,,percent of total billed charges,,,7757.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIBIAL RP CEM SZ7,10435586,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16864.00,5059.20,6543.23,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6543.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14334.4,,,percent of total billed charges,,,7588.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIBIAL RP CEM SZ7,10435586,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16864.00,5059.20,7082.88,14334.4,,8263.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7082.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8506.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7167.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12648.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12648.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14334.4,,,percent of total billed charges,,,7757.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DIAG AL2 6F 100CM,10435590,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,64.00,19.20,27.20,54.40,,39.55,,,percent of total billed charges,,,,,,,,service not payable,31.23,,,percent of total billed charges,,,32.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27.20,,,percent of total billed charges,,,,,,,,,48.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,32.0,,,percent of total billed charges,,,,,,,,service not payable,48.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,41.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,41.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT BONE STANDARD 40GM,10435591,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT BONE STANDARD 40GM,10435591,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM V40 LFIT 26MM -3,10435595,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM V40 LFIT 26MM -3,10435595,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL LONG TI LT 11X420MM,10435596,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6294.00,1888.20,2442.07,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5349.90,,,percent of total billed charges,,,2832.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL LONG TI LT 11X420MM,10435596,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6294.00,1888.20,2643.48,5349.90,,3084.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3174.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5349.90,,,percent of total billed charges,,,2895.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ASSY HUM C/M ELBOW SM 6IN LNG,10435597,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17703.00,5310.90,6868.76,15047.55,,8674.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7435.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6868.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13277.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15047.55,,,percent of total billed charges,,,7966.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASSY HUM C/M ELBOW SM 6IN LNG,10435597,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17703.00,5310.90,7435.26,15047.55,,8674.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7435.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8929.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7523.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13277.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13277.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15047.55,,,percent of total billed charges,,,8143.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS TORIC II 17.5D,10435600,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC II 17.5D,10435600,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PT 97161 EVAL LOW COMPLX,10435776,CDM,0424,RC,97161,CPT,,,,,GP  ,outpatient,facility,,,286.00,85.80,73.33,260.0,,176.75,,,percent of total billed charges,,,91.74,,,fee schedule,,,140.71,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,192.99,,,fee schedule,,,73.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",93.56,,,fee schedule,,,210.68,,,fee schedule,,,,,,,,,91.73,,,fee schedule,,,,,,,,,173.0,,,per diem,,,190.19,,,fee schedule,,,214.5,,,percent of total billed charges,,,91.74,,,fee schedule,,,73.33,,,fee schedule,,,93.57,,,fee schedule,,,204.0,,,per diem,,,91.73,,,fee schedule,,,214.5,,,percent of total billed charges,,,73.33,,,fee schedule,,,93.57,,,fee schedule,,,,,,,,,243.10,,,percent of total billed charges,,,131.56,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,91.73,,,fee schedule,,,,,,,,,229.0,,,per diem,,,91.74,,,fee schedule,,,,,,,,,91.74,,,fee schedule,,,,,,,,
PT 97161 EVAL LOW COMPLX,10435776,CDM,0424,RC,97161,CPT,271,EAPG,,,GP  ,outpatient,facility,,,286.00,85.80,165.39,328.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,279.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,165.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,187.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,206.65,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Driving Student Evaluation-PT,10436019,CDM,0424,RC,99499,CPT,,,,,GP  ,outpatient,facility,,,160.00,48.00,73.60,260.0,,98.88,,,percent of total billed charges,,,,,,,,service not payable,78.08,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,173.0,,,per diem,,,,,,,,,120.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,204.0,,,per diem,,,,,,,,service not payable,120.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,136.0,,,percent of total billed charges,,,73.60,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,service not payable,,,,,,,229.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Driving Student Evaluation-PT,10436019,CDM,0424,RC,99499,CPT,852,EAPG,,,GP  ,outpatient,facility,,,160.00,48.00,160.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,160.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,160.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Driving Student Evaluation-OT,10436020,CDM,0434,RC,99499,CPT,,,,,GO  ,outpatient,facility,,,160.00,48.00,73.60,260.0,,98.88,,,percent of total billed charges,,,,,,,,service not payable,78.08,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,173.0,,,per diem,,,,,,,,,120.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,204.0,,,per diem,,,,,,,,service not payable,120.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,136.0,,,percent of total billed charges,,,73.60,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,service not payable,,,,,,,229.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Driving Student Evaluation-OT,10436020,CDM,0434,RC,99499,CPT,852,EAPG,,,GO  ,outpatient,facility,,,160.00,48.00,160.0,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,160.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,160.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT REV PLATFORM SZ5 14MM,10436195,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV PLATFORM SZ5 14MM,10436195,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHUNT CAROTID SUNDT STRT 4X5MM,10436196,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHUNT CAROTID SUNDT STRT 4X5MM,10436196,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 ST 2.7X28MM,10436202,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,586.00,175.80,227.37,498.10,,,,,,,,,,,,,,,,,,,,227.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,263.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 ST 2.7X28MM,10436202,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,586.00,175.80,249.05,498.10,,,,,,,,,,,,,service not payable,,,,,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,249.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,439.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,293.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,439.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CPR,104365,CDM,0480,RC,92950,CPT,,,,,,outpatient,facility,,,1264.00,379.20,537.20,2075.0,,781.15,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,637.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.20,,,percent of total billed charges,,,,,,,,,948.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,632.0,,,percent of total billed charges,,,,,,,,,948.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1074.40,,,percent of total billed charges,,,581.44,,,percent of total billed charges,,,,,,,,,2075.0,,,per diem,,,,,,,,,,,,,,,1826.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
CPR,104365,CDM,0480,RC,92950,CPT,05722,APC,,,,outpatient,facility,,,1264.00,379.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
CPR,104365,CDM,0480,RC,92950,CPT,92,EAPG,,,,outpatient,facility,,,1264.00,379.20,1022.57,3274.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2783.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1022.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1022.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1839.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2023.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Revascularization tibial/peroneal artery ea addt,10437218,CDM,0481,RC,37232,CPT,,,,,,outpatient,facility,,,13004.00,3901.20,2912.34,12795.0,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,6559.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10876.0,,,case rate,,,,,,,,,9753.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,service not payable,9753.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11053.4,,,percent of total billed charges,,,5981.84,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,service not payable,,,,,,,7234.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Revascularization tibial/peroneal artery ea addt,10437218,CDM,0481,RC,37232,CPT,85,EAPG,,,,outpatient,facility,,,13004.00,3901.20,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13004.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13004.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13004.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Revascularization tibial artery w angioplasty,10437222,CDM,0481,RC,37228,CPT,,,,,,outpatient,facility,,,13004.00,3901.20,5463.36,12795.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,6559.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,9753.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,9753.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11053.4,,,percent of total billed charges,,,5981.84,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Revascularization tibial artery w angioplasty,10437222,CDM,0481,RC,37228,CPT,05193,APC,,,,outpatient,facility,,,13004.00,3901.20,10431.35,24977.68,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22877.78,,,fee schedule,,,10431.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11081.84,,,fee schedule,,,24977.68,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22546.22,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,10431.35,,,fee schedule,,,11081.84,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10431.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",11081.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10972.86,,,fee schedule,,,,,,,,
Revascularization tibial artery w angioplasty,10437222,CDM,0481,RC,37228,CPT,79,EAPG,,,,outpatient,facility,,,13004.00,3901.20,6925.40,15648.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15648.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13301.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6925.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,7617.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Remove/replace pulse generator multiple lead syste,10437225,CDM,0481,RC,33229,CPT,,,,,,outpatient,facility,,,27319.00,8195.70,4917.20,23221.15,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,13779.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,20489.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,20489.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23221.15,,,percent of total billed charges,,,12566.74,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Remove/replace pulse generator multiple lead syste,10437225,CDM,0481,RC,33229,CPT,05224,APC,,,,outpatient,facility,,,27319.00,8195.70,17542.16,42004.34,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,38473.00,,,fee schedule,,,17542.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18612.75,,,fee schedule,,,42004.34,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,37915.42,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,17542.16,,,fee schedule,,,18612.75,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,17542.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",18612.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,18429.93,,,fee schedule,,,,,,,,
Remove/replace pulse generator multiple lead syste,10437225,CDM,0481,RC,33229,CPT,86,EAPG,,,,outpatient,facility,,,27319.00,8195.70,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Atherectomy w/Stent Fem/Pop artery,10437232,CDM,0481,RC,37227,CPT,,,,,,outpatient,facility,,,48649.00,14594.70,5463.36,41351.65,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,24538.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32559.0,,,case rate,,,,,,,,,36486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38305.0,,,case rate,,,,,,,,,36486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41351.65,,,percent of total billed charges,,,22378.54,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,,,,,,,,35346.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Atherectomy w/Stent Fem/Pop artery,10437232,CDM,0481,RC,37227,CPT,05194,APC,,,,outpatient,facility,,,48649.00,14594.70,16517.06,39549.77,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,36224.79,,,fee schedule,,,16517.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17527.09,,,fee schedule,,,39549.77,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,35699.80,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,16517.06,,,fee schedule,,,17527.09,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,16517.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",17527.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,17354.92,,,fee schedule,,,,,,,,
Atherectomy w/Stent Fem/Pop artery,10437232,CDM,0481,RC,37227,CPT,85,EAPG,,,,outpatient,facility,,,48649.00,14594.70,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tx Ventricular Tachycard,10437257,CDM,0481,RC,93654,CPT,,,,,,outpatient,facility,,,36205.00,10861.50,8909.33,30774.25,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,18261.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,27153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,27153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30774.25,,,percent of total billed charges,,,16654.30,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tx Ventricular Tachycard,10437257,CDM,0481,RC,93654,CPT,05213,APC,,,,outpatient,facility,,,36205.00,10861.50,22565.46,54032.53,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,49489.97,,,fee schedule,,,22565.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",23932.83,,,fee schedule,,,54032.53,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,48772.73,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,22565.46,,,fee schedule,,,23932.83,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,22565.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",23932.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,23697.85,,,fee schedule,,,,,,,,
Tx Ventricular Tachycard,10437257,CDM,0481,RC,93654,CPT,82,EAPG,,,,outpatient,facility,,,36205.00,10861.50,23479.06,28514.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27622.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23479.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25922.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,28514.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GLENOSPHERE 38MM 0MM,10437269,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE 38MM 0MM,10437269,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT STENT ILIAC LEG 16X39MM,10437270,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,12713.00,3813.90,4932.64,10806.05,,6229.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5339.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4932.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5403.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9534.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6356.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10806.05,,,percent of total billed charges,,,5720.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT STENT ILIAC LEG 16X39MM,10437270,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,12713.00,3813.90,5339.46,10806.05,,6229.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5339.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6412.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5403.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9534.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6356.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9534.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10806.05,,,percent of total billed charges,,,5847.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR LT SZ3-4 12MM,10437271,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR LT SZ3-4 12MM,10437271,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL 14MMX79/83MM,10437272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3541.00,1062.30,1373.91,3009.85,,,,,,,,,,,,,,,,,,,,1373.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.85,,,percent of total billed charges,,,1593.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL 14MMX79/83MM,10437272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3541.00,1062.30,1504.92,3009.85,,,,,,,,,,,,,service not payable,,,,,,,1786.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3009.85,,,percent of total billed charges,,,1628.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PIP ST 12MM,10437273,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PIP ST 12MM,10437273,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BALLOON PTA 2X210MM,10437274,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,1452.3,,,percent of total billed charges,,,,,,,,service not payable,1146.8,,,percent of total billed charges,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE SM AUG REV SHOULDER,10437275,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE SM AUG REV SHOULDER,10437275,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL 2.5 20MM,10437276,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL 2.5 20MM,10437276,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DRAINAGE UNIV 1000ML,10437284,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,152.65,,,percent of total billed charges,,,,,,,,service not payable,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DRAINAGE UNIV 1000ML - 4,10437285,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,152.65,,,percent of total billed charges,,,,,,,,service not payable,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH URINARY DOVER 22F 30ML,10437286,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,63.00,18.90,26.77,53.55,,38.93,,,percent of total billed charges,,,,,,,,service not payable,30.74,,,percent of total billed charges,,,31.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,26.77,,,percent of total billed charges,,,,,,,,,47.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,31.5,,,percent of total billed charges,,,,,,,,service not payable,47.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,53.55,,,percent of total billed charges,,,28.98,,,percent of total billed charges,,,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN OZARK TEMP FIX COARSE,10437287,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1012.00,303.60,392.66,860.20,,,,,,,,,,,,,,,,,,,,392.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,430.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,759.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,506.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,860.20,,,percent of total billed charges,,,455.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN OZARK TEMP FIX COARSE,10437287,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1012.00,303.60,430.10,860.20,,,,,,,,,,,,,service not payable,,,,,,,510.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,430.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,759.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,506.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,759.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,860.20,,,percent of total billed charges,,,465.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 3X13MM,10437288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,861.00,258.30,334.07,731.85,,,,,,,,,,,,,,,,,,,,334.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.85,,,percent of total billed charges,,,387.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 3X13MM,10437288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,861.00,258.30,365.93,731.85,,,,,,,,,,,,,service not payable,,,,,,,434.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,645.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,396.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS TRANSCATHETER PACING MICRA,10437294,CDM,0275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,34421.00,10326.30,13355.35,29257.85,,16866.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14456.82,,,percent of total billed charges,,Paid in addition to inpatient services ,13355.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14628.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,25815.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17210.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29257.85,,,percent of total billed charges,,,15489.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS TRANSCATHETER PACING MICRA,10437294,CDM,0275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,34421.00,10326.30,14456.82,29257.85,,16866.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14456.82,,,percent of total billed charges,,Paid in addition to outpatient services ,17361.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14628.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,25815.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17210.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,25815.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29257.85,,,percent of total billed charges,,,15833.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL SZ1,10437596,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL SZ1,10437596,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT BEARING TIB,10437597,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT BEARING TIB,10437597,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE EXPANDABLE 10X28MM 12DEG,10437598,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE EXPANDABLE 10X28MM 12DEG,10437598,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE BONE JAWS 10X10MM DISP,10437599,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4318.00,1295.40,1675.38,3670.30,,,,,,,,,,,,,,,,,,,,1675.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1835.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2159.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3670.30,,,percent of total billed charges,,,1943.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE BONE JAWS 10X10MM DISP,10437599,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4318.00,1295.40,1835.15,3670.30,,,,,,,,,,,,,service not payable,,,,,,,2178.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1835.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3238.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2159.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3670.30,,,percent of total billed charges,,,1986.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE LAP ANG 5D 5MM,10437600,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5802.00,1740.60,2251.18,4931.70,,2842.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2436.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2251.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2465.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4351.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2901.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4931.70,,,percent of total billed charges,,,2610.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE LAP ANG 5D 5MM,10437600,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5802.00,1740.60,2436.84,4931.70,,2842.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2436.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2926.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2465.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4351.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2901.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4351.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4931.70,,,percent of total billed charges,,,2668.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HDLS ST MM 3.5X26MM,10437601,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1360.00,408.00,527.68,1156.0,,,,,,,,,,,,,,,,,,,,527.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,,612.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HDLS ST MM 3.5X26MM,10437601,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1360.00,408.00,578.0,1156.0,,,,,,,,,,,,,service not payable,,,,,,,685.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,,625.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HDLS ST MM 3.5X48MM,10437602,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1360.00,408.00,527.68,1156.0,,,,,,,,,,,,,,,,,,,,527.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.0,,,percent of total billed charges,,,612.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HDLS ST MM 3.5X48MM,10437602,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1360.00,408.00,578.0,1156.0,,,,,,,,,,,,,service not payable,,,,,,,685.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,578.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1020.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1020.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1156.0,,,percent of total billed charges,,,625.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TRACHEOBRONCHIAL 7X22MM,10437603,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8189.00,2456.70,3177.33,6960.65,,4012.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3439.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3177.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3480.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4094.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6960.65,,,percent of total billed charges,,,3685.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TRACHEOBRONCHIAL 7X22MM,10437603,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8189.00,2456.70,3439.38,6960.65,,4012.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3439.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4130.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3480.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4094.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6960.65,,,percent of total billed charges,,,3766.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN LT 10X420MM 130D,10437604,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN LT 10X420MM 130D,10437604,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PERF NAIL 10.5X100MM,10437605,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3312.00,993.60,1285.06,2815.20,,,,,,,,,,,,,,,,,,,,1285.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2484.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1656.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2815.20,,,percent of total billed charges,,,1490.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERF NAIL 10.5X100MM,10437605,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3312.00,993.60,1407.60,2815.20,,,,,,,,,,,,,service not payable,,,,,,,1670.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2484.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1656.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2484.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2815.20,,,percent of total billed charges,,,1523.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SHAFT FEMUR 210MM X 3MM,10437607,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SHAFT FEMUR 210MM X 3MM,10437607,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Unlisted Cardiovascular Procedure,10447385,CDM,0481,RC,93799,CPT,,,,,,outpatient,facility,,,1710.00,513.00,786.60,1775.0,,1056.78,,,percent of total billed charges,,,,,,,,,834.48,,,percent of total billed charges,,,862.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,1282.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,1282.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1453.5,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Unlisted Cardiovascular Procedure,10447385,CDM,0481,RC,93799,CPT,05721,APC,,,,outpatient,facility,,,1710.00,513.00,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Unlisted Cardiovascular Procedure,10447385,CDM,0481,RC,93799,CPT,413,EAPG,,,,outpatient,facility,,,1710.00,513.00,37.41,195.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,165.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,37.41,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,37.41,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,61.38,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,67.52,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tx Lt/Rt Atrial Fib addtl,10447888,CDM,0481,RC,93657,CPT,,,,,,outpatient,facility,,,1201.00,360.30,552.46,2912.34,,1201.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,605.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,900.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,900.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1020.85,,,percent of total billed charges,,,552.46,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Tx Lt/Rt Atrial Fib addtl,10447888,CDM,0481,RC,93657,CPT,82,EAPG,,,,outpatient,facility,,,1201.00,360.30,1201.0,28514.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27622.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23479.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1201.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1201.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1201.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25922.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,28514.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT FISTULA 4.0X7.0CM,10448355,CDM,0278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,3030.00,909.00,1175.64,2575.5,,,,,,,,,,,,,,,,,,,,1175.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1287.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1515.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2575.5,,,percent of total billed charges,,,1363.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FISTULA 4.0X7.0CM,10448355,CDM,0278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,3030.00,909.00,1287.75,2575.5,,,,,,,,,,,,,service not payable,,,,,,,1528.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1287.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2272.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1515.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2575.5,,,percent of total billed charges,,,1393.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT J DIV 7.0F 90CM,10448361,CDM,0272,RC,C2625,HCPCS,,,,,,outpatient,facility,,,1235.00,370.50,524.88,1049.75,,763.23,,,percent of total billed charges,,,,,,,,service not payable,602.68,,,percent of total billed charges,,,622.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,524.88,,,percent of total billed charges,,,,,,,,,926.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,617.5,,,percent of total billed charges,,,,,,,,service not payable,926.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1049.75,,,percent of total billed charges,,,568.10,,,percent of total billed charges,,,,,,,,,802.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,802.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT X3 TRIATHLON PS 6 14MM,10448373,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT X3 TRIATHLON PS 6 14MM,10448373,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE 42MM 0MM,10448374,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE 42MM 0MM,10448374,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB RP CEM SZ9,10448375,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3349.00,1004.70,1299.41,2846.65,,,,,,,,,,,,,,,,,,,,1299.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2511.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1674.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2846.65,,,percent of total billed charges,,,1507.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB RP CEM SZ9,10448375,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3349.00,1004.70,1423.32,2846.65,,,,,,,,,,,,,service not payable,,,,,,,1689.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1423.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2511.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1674.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2511.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2846.65,,,percent of total billed charges,,,1540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING GRANUF NP SIMPLACE MD,10448376,CDM,0272,RC,A6209,HCPCS,,,,,,outpatient,facility,,,258.00,77.40,109.65,219.30,,159.44,,,percent of total billed charges,,,,,,,,service not payable,125.90,,,percent of total billed charges,,,130.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,109.65,,,percent of total billed charges,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,129.0,,,percent of total billed charges,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,219.30,,,percent of total billed charges,,,118.68,,,percent of total billed charges,,,,,,,,,167.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,167.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRESSING GRANUF NP SIMPLACE SM,10448378,CDM,0272,RC,A6209,HCPCS,,,,,,outpatient,facility,,,186.00,55.80,79.05,158.10,,114.95,,,percent of total billed charges,,,,,,,,service not payable,90.77,,,percent of total billed charges,,,93.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,79.05,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,93.0,,,percent of total billed charges,,,,,,,,service not payable,139.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,,85.56,,,percent of total billed charges,,,,,,,,,120.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,120.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV SPINE 4DEG 9MM,10448381,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3642.00,1092.60,1413.10,3095.70,,,,,,,,,,,,,,,,,,,,1413.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1547.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2731.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3095.70,,,percent of total billed charges,,,1638.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV SPINE 4DEG 9MM,10448381,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3642.00,1092.60,1547.85,3095.70,,,,,,,,,,,,,service not payable,,,,,,,1837.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1547.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2731.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1821.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2731.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3095.70,,,percent of total billed charges,,,1675.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 3.5X36MM,10448382,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 3.5X36MM,10448382,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 21X21X10CM 18F,10448384,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 21X21X10CM 18F,10448384,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 26X21X10CM 20F,10448385,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 26X21X10CM 20F,10448385,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 26X26X10CM 20F,10448386,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 26X26X10CM 20F,10448386,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 28X28X10CM 20F,10448387,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 28X28X10CM 20F,10448387,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 28X28X15CM 20F,10448388,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 28X28X15CM 20F,10448388,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 34X34X10CM 22F,10448389,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 34X34X10CM 22F,10448389,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 34X34X15CM 22F,10448390,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 34X34X15CM 22F,10448390,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 34X34X20CM 22F,10448391,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 34X34X20CM 22F,10448391,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 45X45X10CM 24F,10448392,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 45X45X10CM 24F,10448392,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 45X45X15CM 24F,10448393,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 45X45X15CM 24F,10448393,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 45X45X20CM 24F,10448394,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 45X45X20CM 24F,10448394,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 31X26X10CM 20F,10448395,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 31X26X10CM 20F,10448395,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 31X31X10CM 20F,10448396,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 31X31X10CM 20F,10448396,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 31X31X15CM 20F,10448397,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 31X31X15CM 20F,10448397,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 31X31X20CM 20F,10448398,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 31X31X20CM 20F,10448398,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 37X37X10CM 22F,10448399,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 37X37X10CM 22F,10448399,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 37X37X15CM 22F,10448400,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 37X37X15CM 22F,10448400,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 37X37X20CM 22F,10448401,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 37X37X20CM 22F,10448401,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 40X40X10CM 22F,10448402,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 40X40X10CM 22F,10448402,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 40X40X15CM 22F,10448403,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 40X40X15CM 22F,10448403,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT TAG THOR 40X40X20CM 22F,10448404,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,43365.00,13009.50,16825.62,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16825.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36860.25,,,percent of total billed charges,,,19514.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT TAG THOR 40X40X20CM 22F,10448404,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,43365.00,13009.50,18213.30,36860.25,,21248.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18213.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21873.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18430.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32523.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21682.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32523.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36860.25,,,percent of total billed charges,,,19947.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST MEDIAL 8H LT 149MM,10448405,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7509.00,2252.70,2913.49,6382.65,,3679.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3153.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2913.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3191.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5631.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3754.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6382.65,,,percent of total billed charges,,,3379.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST MEDIAL 8H LT 149MM,10448405,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7509.00,2252.70,3153.78,6382.65,,3679.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3153.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3787.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3191.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5631.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3754.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5631.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6382.65,,,percent of total billed charges,,,3454.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX TI 3.5X18MM,10448406,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,262.00,78.60,101.66,222.70,,,,,,,,,,,,,,,,,,,,101.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,196.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.70,,,percent of total billed charges,,,117.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX TI 3.5X18MM,10448406,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,262.00,78.60,111.35,222.70,,,,,,,,,,,,,service not payable,,,,,,,132.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,111.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,196.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,196.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,222.70,,,percent of total billed charges,,,120.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NM Exam,10448644,CDM,0340,RC,78802,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,623.07,7883.75,,835.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,623.07,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10448644,CDM,0340,RC,78802,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10448644,CDM,0340,RC,78802,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10448646,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,4600.00,1380.00,375.0,3910.0,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,2320.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2300.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3910.0,,,percent of total billed charges,,,2116.0,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10448646,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,4600.00,1380.00,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10448646,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,4600.00,1380.00,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NM Exam,10448648,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM Exam,10448648,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
NM Exam,10448648,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Comp EP Eval and Ablate Supraventricular Arrhythmi,10448659,CDM,0481,RC,93653,CPT,,,,,,outpatient,facility,,,36205.00,10861.50,8909.33,30774.25,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,18261.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24481.0,,,case rate,,,,,,,,,27153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28801.0,,,case rate,,,,,,,,,27153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30774.25,,,percent of total billed charges,,,16654.30,,,percent of total billed charges,,,,,,,,,26782.0,,,case rate,,,,,,,,,,,,,,,23568.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Comp EP Eval and Ablate Supraventricular Arrhythmi,10448659,CDM,0481,RC,93653,CPT,05213,APC,,,,outpatient,facility,,,36205.00,10861.50,22565.46,54032.53,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,49489.97,,,fee schedule,,,22565.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",23932.83,,,fee schedule,,,54032.53,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,48772.73,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,22565.46,,,fee schedule,,,23932.83,,,fee schedule,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,22565.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",23932.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,,,,,,,23463.56,,,fee schedule,,,,,,,,,23697.85,,,fee schedule,,,,,,,,
Comp EP Eval and Ablate Supraventricular Arrhythmi,10448659,CDM,0481,RC,93653,CPT,82,EAPG,,,,outpatient,facility,,,36205.00,10861.50,23479.06,28514.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27622.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23479.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25427.10,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,25922.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,28514.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT I-131 Sngl Area 1 Day,10448906,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,4600.00,1380.00,375.0,3910.0,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,2320.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2300.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3910.0,,,percent of total billed charges,,,2116.0,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT I-131 Sngl Area 1 Day,10448906,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,4600.00,1380.00,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT I-131 Sngl Area 1 Day,10448906,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,4600.00,1380.00,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT I-131 Sngl Area 1 Day,10448908,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT I-131 Sngl Area 1 Day,10448908,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT I-131 Sngl Area 1 Day,10448908,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PET CT Y90 Post Treatment Limited,10448910,CDM,0404,RC,78814,CPT,,,,,52  ,outpatient,facility,,,4600.00,1380.00,1955.0,3910.0,,2505.91,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE Paid in addition to outpatient services",,,,,,,1990.0,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE Paid in addition to outpatient services",2320.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2300.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3910.0,,,percent of total billed charges,,,2116.0,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PET CT Y90 Post Treatment Limited,10448910,CDM,0404,RC,78814,CPT,05594,APC,,,52  ,outpatient,facility,,,4600.00,1380.00,670.83,1606.27,,,,,,,,699.37,,,fee schedule,,,,,,,,,,,,,,,1471.23,,,fee schedule,,,670.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",713.36,,,fee schedule,,,1606.27,,,fee schedule,,,,,,,,,699.37,,,fee schedule,,,,,,,,,,,,,,,1449.91,,,fee schedule,,,,,,,,,699.37,,,fee schedule,,,670.83,,,fee schedule,,,713.36,,,fee schedule,,,,,,,,,699.37,,,fee schedule,,,,,,,,,670.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",713.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.37,,,fee schedule,,,,,,,,,,,,,,,699.37,,,fee schedule,,,,,,,,,706.34,,,fee schedule,,,,,,,,
PET CT Y90 Post Treatment Limited,10448910,CDM,0404,RC,78814,CPT,290,EAPG,,,52  ,outpatient,facility,,,4600.00,1380.00,970.56,2502.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2502.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2127.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.56,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,970.56,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,970.56,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1487.38,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1636.12,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT CT I-131 Sngl Area 1 Day,10448911,CDM,0340,RC,78830,CPT,,,,,,outpatient,facility,,,4600.00,1380.00,375.0,3910.0,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,2320.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2300.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3910.0,,,percent of total billed charges,,,2116.0,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT CT I-131 Sngl Area 1 Day,10448911,CDM,0340,RC,78830,CPT,05593,APC,,,,outpatient,facility,,,4600.00,1380.00,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT CT I-131 Sngl Area 1 Day,10448911,CDM,0340,RC,78830,CPT,332,EAPG,,,,outpatient,facility,,,4600.00,1380.00,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPECT I-131 Sngl Area 1 Day,10448912,CDM,0340,RC,78803,CPT,,,,,,outpatient,facility,,,9275.00,2782.50,637.51,7883.75,,854.37,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,637.51,,,fee schedule,,,4678.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3941.88,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4637.5,,,percent of total billed charges,,,,,,,,,6956.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7883.75,,,percent of total billed charges,,,4266.5,,,percent of total billed charges,,,,,,,,,2976.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPECT I-131 Sngl Area 1 Day,10448912,CDM,0340,RC,78803,CPT,05593,APC,,,,outpatient,facility,,,9275.00,2782.50,1200.81,2875.33,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2633.60,,,fee schedule,,,1200.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1276.95,,,fee schedule,,,2875.33,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,2595.43,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,1200.81,,,fee schedule,,,1276.95,,,fee schedule,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1200.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1276.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,,,,,,,1251.91,,,fee schedule,,,,,,,,,1264.38,,,fee schedule,,,,,,,,
SPECT I-131 Sngl Area 1 Day,10448912,CDM,0340,RC,78803,CPT,332,EAPG,,,,outpatient,facility,,,9275.00,2782.50,1280.52,3470.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3470.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2950.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1280.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1703.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1874.14,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PET CT Y90 Post Treatment Limited,10448913,CDM,0404,RC,78814,CPT,,,,,52  ,outpatient,facility,,,4600.00,1380.00,1955.0,3910.0,,2505.91,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE Paid in addition to outpatient services",,,,,,,1990.0,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE Paid in addition to outpatient services",2320.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1955.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2300.0,,,percent of total billed charges,,,,,,,,,3450.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3910.0,,,percent of total billed charges,,,2116.0,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PET CT Y90 Post Treatment Limited,10448913,CDM,0404,RC,78814,CPT,05594,APC,,,52  ,outpatient,facility,,,4600.00,1380.00,670.83,1606.27,,,,,,,,699.37,,,fee schedule,,,,,,,,,,,,,,,1471.23,,,fee schedule,,,670.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",713.36,,,fee schedule,,,1606.27,,,fee schedule,,,,,,,,,699.37,,,fee schedule,,,,,,,,,,,,,,,1449.91,,,fee schedule,,,,,,,,,699.37,,,fee schedule,,,670.83,,,fee schedule,,,713.36,,,fee schedule,,,,,,,,,699.37,,,fee schedule,,,,,,,,,670.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",713.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.37,,,fee schedule,,,,,,,,,,,,,,,699.37,,,fee schedule,,,,,,,,,706.34,,,fee schedule,,,,,,,,
PET CT Y90 Post Treatment Limited,10448913,CDM,0404,RC,78814,CPT,290,EAPG,,,52  ,outpatient,facility,,,4600.00,1380.00,970.56,2502.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2502.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2127.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.56,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,970.56,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,970.56,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1487.38,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1636.12,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CD3 Level,10449394,CDM,0300,RC,86355,CPT,,,,,,outpatient,facility,,,63.00,18.90,28.98,85.27,,63.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,36.98,,,fee schedule,,,63.0,,,fee schedule,,,78.69,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,78.10,,,fee schedule,,,35.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",37.72,,,fee schedule,,,85.27,,,fee schedule,,,,,,,,,36.98,,,fee schedule,,,,,,,,,48.45,,,fee schedule,,,76.97,,,fee schedule,,,47.25,,,percent of total billed charges,,,36.98,,,fee schedule,,,35.84,,,fee schedule,,,37.72,,,fee schedule,,,56.97,,,fee schedule,,,36.98,,,fee schedule,,,47.25,,,percent of total billed charges,,,,,,,,,37.72,,,fee schedule,,,,,,,,,53.55,,,percent of total billed charges,,,28.98,,,percent of total billed charges,,,,,,,,,41.5,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,36.60,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,37.35,,,fee schedule,,,,,,,,
CD3 Level,10449394,CDM,0300,RC,86355,CPT,395,EAPG,,,,outpatient,facility,,,63.00,18.90,48.13,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CD3 Level - NK Cells,10449412,CDM,0300,RC,86357,CPT,,,,,,outpatient,facility,,,48.00,14.40,22.08,85.27,,48.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,36.98,,,fee schedule,,,48.0,,,fee schedule,,,78.69,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,78.10,,,fee schedule,,,35.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",37.72,,,fee schedule,,,85.27,,,fee schedule,,,,,,,,,36.98,,,fee schedule,,,,,,,,,48.45,,,fee schedule,,,76.97,,,fee schedule,,,36.0,,,percent of total billed charges,,,36.98,,,fee schedule,,,35.84,,,fee schedule,,,37.72,,,fee schedule,,,56.97,,,fee schedule,,,36.98,,,fee schedule,,,36.0,,,percent of total billed charges,,,,,,,,,37.72,,,fee schedule,,,,,,,,,40.80,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,,,,,,,41.5,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,36.60,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,37.35,,,fee schedule,,,,,,,,
CD3 Level - NK Cells,10449412,CDM,0300,RC,86357,CPT,395,EAPG,,,,outpatient,facility,,,48.00,14.40,48.0,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CD3 Level - T Cells,10449413,CDM,0300,RC,86359,CPT,,,,,,outpatient,facility,,,48.00,14.40,22.08,85.27,,48.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,36.98,,,fee schedule,,,48.0,,,fee schedule,,,78.69,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,78.10,,,fee schedule,,,35.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",37.72,,,fee schedule,,,85.27,,,fee schedule,,,,,,,,,36.98,,,fee schedule,,,,,,,,,48.45,,,fee schedule,,,76.97,,,fee schedule,,,36.0,,,percent of total billed charges,,,36.98,,,fee schedule,,,35.84,,,fee schedule,,,37.72,,,fee schedule,,,56.97,,,fee schedule,,,36.98,,,fee schedule,,,36.0,,,percent of total billed charges,,,,,,,,,37.72,,,fee schedule,,,,,,,,,40.80,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,,,,,,,41.5,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,36.60,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,37.35,,,fee schedule,,,,,,,,
CD3 Level - T Cells,10449413,CDM,0300,RC,86359,CPT,395,EAPG,,,,outpatient,facility,,,48.00,14.40,48.0,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CORT ST NCB 5X26,10449475,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,793.00,237.90,307.68,674.05,,,,,,,,,,,,,,,,,,,,307.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,356.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST NCB 5X26,10449475,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,,,,,,,,,,,,service not payable,,,,,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST NCB 5X28,10449476,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,793.00,237.90,307.68,674.05,,,,,,,,,,,,,,,,,,,,307.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,356.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST NCB 5X28,10449476,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,,,,,,,,,,,,service not payable,,,,,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB LT 5,10449477,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6822.00,2046.60,2646.94,5798.70,,3342.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2865.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2646.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2899.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5116.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3411.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5798.70,,,percent of total billed charges,,,3069.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB LT 5,10449477,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6822.00,2046.60,2865.24,5798.70,,3342.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2865.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3441.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2899.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5116.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3411.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5116.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5798.70,,,percent of total billed charges,,,3138.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 7 HOLE DIST FIB 2.7,10449478,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3726.00,1117.80,1445.69,3167.10,,,,,,,,,,,,,,,,,,,,1445.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2794.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1863.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3167.10,,,percent of total billed charges,,,1676.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 7 HOLE DIST FIB 2.7,10449478,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3726.00,1117.80,1583.55,3167.10,,,,,,,,,,,,,service not payable,,,,,,,1879.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1583.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2794.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1863.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2794.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3167.10,,,percent of total billed charges,,,1713.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN EVOS 2.0X14MM PF SMALL,10449479,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,827.00,248.10,320.88,702.95,,,,,,,,,,,,,,,,,,,,320.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,620.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,413.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,702.95,,,percent of total billed charges,,,372.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN EVOS 2.0X14MM PF SMALL,10449479,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,827.00,248.10,351.47,702.95,,,,,,,,,,,,,service not payable,,,,,,,417.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,351.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,620.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,413.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,620.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,702.95,,,percent of total billed charges,,,380.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7X14MM,10449480,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1885.00,565.50,731.38,1602.25,,,,,,,,,,,,,,,,,,,,731.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.25,,,percent of total billed charges,,,848.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7X14MM,10449480,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1885.00,565.50,801.12,1602.25,,,,,,,,,,,,,service not payable,,,,,,,950.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1602.25,,,percent of total billed charges,,,867.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7X16MM,10449481,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1885.00,565.50,731.38,1602.25,,,,,,,,,,,,,,,,,,,,731.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.25,,,percent of total billed charges,,,848.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7X16MM,10449481,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1885.00,565.50,801.12,1602.25,,,,,,,,,,,,,service not payable,,,,,,,950.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1602.25,,,percent of total billed charges,,,867.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7 X 48MM,10449482,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1885.00,565.50,731.38,1602.25,,,,,,,,,,,,,,,,,,,,731.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.25,,,percent of total billed charges,,,848.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7 X 48MM,10449482,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1885.00,565.50,801.12,1602.25,,,,,,,,,,,,,service not payable,,,,,,,950.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1602.25,,,percent of total billed charges,,,867.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 2.7 X 55MM,10449483,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1885.00,565.50,731.38,1602.25,,,,,,,,,,,,,,,,,,,,731.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.25,,,percent of total billed charges,,,848.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 2.7 X 55MM,10449483,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1885.00,565.50,801.12,1602.25,,,,,,,,,,,,,service not payable,,,,,,,950.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,801.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1602.25,,,percent of total billed charges,,,867.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 3.5 X 11MM,10449484,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 3.5 X 11MM,10449484,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX EVOS 3.5 X 38MM,10449485,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX EVOS 3.5 X 38MM,10449485,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIBULA LT DISTAL 2.7 5 H,10449489,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2508.00,752.40,973.10,2131.80,,,,,,,,,,,,,,,,,,,,973.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1065.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1881.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2131.80,,,percent of total billed charges,,,1128.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIBULA LT DISTAL 2.7 5 H,10449489,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2508.00,752.40,1065.90,2131.80,,,,,,,,,,,,,service not payable,,,,,,,1265.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1065.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1881.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1254.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1881.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2131.80,,,percent of total billed charges,,,1153.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 5F 6X150MM 130CM,10449490,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2438.65,4877.30,,3546.08,,,percent of total billed charges,,,,,,,,service not payable,2800.14,,,percent of total billed charges,,,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2869.0,,,percent of total billed charges,,,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE KIRSCHNER 0.045X4IN,10449499,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,79.00,23.70,30.65,67.15,,,,,,,,,,,,,,,,,,,,30.65,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,59.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.15,,,percent of total billed charges,,,35.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE KIRSCHNER 0.045X4IN,10449499,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,79.00,23.70,33.57,67.15,,,,,,,,,,,,,service not payable,,,,,,,39.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,33.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,59.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,39.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,59.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,67.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Removal/Replace Pacemaker Dual Chamber Lead Sys,10449730,CDM,0481,RC,33228,CPT,,,,,,outpatient,facility,,,21036.00,6310.80,4917.20,18583.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,10610.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,15777.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,15777.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17880.60,,,percent of total billed charges,,,9676.56,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal/Replace Pacemaker Dual Chamber Lead Sys,10449730,CDM,0481,RC,33228,CPT,05223,APC,,,,outpatient,facility,,,21036.00,6310.80,9626.29,23049.94,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,21112.12,,,fee schedule,,,9626.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10229.20,,,fee schedule,,,23049.94,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,20806.14,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,9626.29,,,fee schedule,,,10229.20,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,9626.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",10229.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,10128.58,,,fee schedule,,,,,,,,
Removal/Replace Pacemaker Dual Chamber Lead Sys,10449730,CDM,0481,RC,33228,CPT,86,EAPG,,,,outpatient,facility,,,21036.00,6310.80,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WALKER INLINE PNEUMA SHR MD,10449928,CDM,0274,RC,L4631,HCPCS,,,,,,inpatient,facility,,,140.00,42.00,54.32,119.0,,,,,,,,,,,,,,,,,,,,54.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,,63.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER INLINE PNEUMA SHR MD,10449928,CDM,0274,RC,L4631,HCPCS,,,,,,outpatient,facility,,,140.00,42.00,59.5,316.40,,,,,,,,137.76,,,fee schedule,,,,,,,,,70.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,289.80,,,fee schedule,,,140.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",140.52,,,fee schedule,,,316.40,,,fee schedule,,,,,,,,,137.76,,,fee schedule,,,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to outpatient services ,285.60,,,fee schedule,,,105.0,,,percent of total billed charges,,,137.76,,,fee schedule,,,140.0,,,fee schedule,,,140.52,,,fee schedule,,,70.0,,,percent of total billed charges,,Paid in addition to outpatient services ,137.76,,,fee schedule,,,105.0,,,percent of total billed charges,,,140.0,,,fee schedule,,,140.52,,,fee schedule,,,,,,,,,119.0,,,percent of total billed charges,,,64.40,,,percent of total billed charges,,,,,,,,,,,,,,,137.76,,,fee schedule,,,,,,,,,,,,,,,137.76,,,fee schedule,,,,,,,,,137.76,,,fee schedule,,,,,,,,
SUPPORT WALKER EQUALIZER LG,10449929,CDM,0274,RC,L4631,HCPCS,,,,,,inpatient,facility,,,192.00,57.60,74.50,163.20,,,,,,,,,,,,,,,,,,,,74.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,144.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,,86.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUPPORT WALKER EQUALIZER LG,10449929,CDM,0274,RC,L4631,HCPCS,,,,,,outpatient,facility,,,192.00,57.60,81.60,433.92,,,,,,,,188.93,,,fee schedule,,,,,,,,,96.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,397.44,,,fee schedule,,,192.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",192.71,,,fee schedule,,,433.92,,,fee schedule,,,,,,,,,188.93,,,fee schedule,,,,,,,,,81.60,,,percent of total billed charges,,Paid in addition to outpatient services ,391.68,,,fee schedule,,,144.0,,,percent of total billed charges,,,188.93,,,fee schedule,,,192.0,,,fee schedule,,,192.71,,,fee schedule,,,96.0,,,percent of total billed charges,,Paid in addition to outpatient services ,188.93,,,fee schedule,,,144.0,,,percent of total billed charges,,,192.0,,,fee schedule,,,192.71,,,fee schedule,,,,,,,,,163.20,,,percent of total billed charges,,,88.32,,,percent of total billed charges,,,,,,,,,,,,,,,188.93,,,fee schedule,,,,,,,,,,,,,,,188.93,,,fee schedule,,,,,,,,,188.93,,,fee schedule,,,,,,,,
STENT ENDOPROS THORACIC 40X40M,10450397,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,36751.00,11025.30,14259.39,31238.35,,18007.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15435.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14259.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15619.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27563.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18375.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31238.35,,,percent of total billed charges,,,16537.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS THORACIC 40X40M,10450397,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,36751.00,11025.30,15435.42,31238.35,,18007.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15435.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18537.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15619.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27563.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18375.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27563.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31238.35,,,percent of total billed charges,,,16905.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRO DRYSEAL 24FRX33MM,10450398,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE SIGMA PFC DIS LT 2.5 4MM,10450399,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3550.00,1065.00,1377.40,3017.5,,,,,,,,,,,,,,,,,,,,1377.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.5,,,percent of total billed charges,,,1597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE SIGMA PFC DIS LT 2.5 4MM,10450399,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3550.00,1065.00,1508.75,3017.5,,,,,,,,,,,,,service not payable,,,,,,,1790.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1508.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2662.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2662.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3017.5,,,percent of total billed charges,,,1633.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT GNS II CON SZ3-4 18MM,10450400,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8728.00,2618.40,3386.46,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3386.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7418.80,,,percent of total billed charges,,,3927.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT GNS II CON SZ3-4 18MM,10450400,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8728.00,2618.40,3665.76,7418.80,,4276.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3665.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4402.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3709.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6546.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4364.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6546.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7418.80,,,percent of total billed charges,,,4014.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM PROX LAT RT 4H 99MM,10450401,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7548.00,2264.40,2928.62,6415.80,,3698.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3170.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2928.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3207.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5661.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3774.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6415.80,,,percent of total billed charges,,,3396.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM PROX LAT RT 4H 99MM,10450401,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7548.00,2264.40,3170.16,6415.80,,3698.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3170.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3807.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3207.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5661.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3774.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5661.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6415.80,,,percent of total billed charges,,,3472.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Programming device evaluation multiple lead pacema,10450453,CDM,0481,RC,93281,CPT,,,,,,outpatient,facility,,,114.00,34.20,48.45,96.90,,65.61,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,48.95,,,fee schedule,,,57.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.45,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.0,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.90,,,percent of total billed charges,,,52.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Programming device evaluation multiple lead pacema,10450453,CDM,0481,RC,93281,CPT,05741,APC,,,,outpatient,facility,,,114.00,34.20,34.30,82.13,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,75.22,,,fee schedule,,,34.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",36.48,,,fee schedule,,,82.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,74.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,34.30,,,fee schedule,,,36.48,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,34.30,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",36.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,36.11,,,fee schedule,,,,,,,,
Programming device evaluation multiple lead pacema,10450453,CDM,0481,RC,93281,CPT,488,EAPG,,,,outpatient,facility,,,114.00,34.20,52.57,109.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,93.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,91.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,100.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH FOLEY BARDEX UM TRAY 16FR X_A303316A X_351317,10450963,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,119.00,35.70,50.58,101.15,,73.54,,,percent of total billed charges,,,,,,,,service not payable,58.07,,,percent of total billed charges,,,60.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,50.58,,,percent of total billed charges,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,,,,,,service not payable,89.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,101.15,,,percent of total billed charges,,,54.74,,,percent of total billed charges,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,77.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TISSUE ALLOGRAFT 4 SQ COM X_GS-5220 X_349700,10451022,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3530.00,1059.00,1369.64,3000.5,,,,,,,,,,,,,,,,,,,,1369.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1500.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2647.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3000.5,,,percent of total billed charges,,,1588.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE ALLOGRAFT 4 SQ COM X_GS-5220 X_349700,10451022,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3530.00,1059.00,1500.25,3000.5,,,,,,,,,,,,,service not payable,,,,,,,1780.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1500.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2647.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1765.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2647.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3000.5,,,percent of total billed charges,,,1623.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY FOLEY SURESTEP URINE MTR,10451271,CDM,0272,RC,A4315,HCPCS,,,,,,outpatient,facility,,,78.00,23.40,33.15,66.30,,48.20,,,percent of total billed charges,,,,,,,,service not payable,38.06,,,percent of total billed charges,,,39.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,39.0,,,percent of total billed charges,,,,,,,,service not payable,58.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,66.30,,,percent of total billed charges,,,35.88,,,percent of total billed charges,,,,,,,,,50.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,50.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW YUKON POLYAXIAL 3.5X12MM,10451272,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW YUKON POLYAXIAL 3.5X12MM,10451272,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW YUKON POLYAXIAL 3.5X20MM,10451273,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW YUKON POLYAXIAL 3.5X20MM,10451273,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR TRANSVERSE,10451274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR TRANSVERSE,10451274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM PTC LONG FLEX SZ2B,10451612,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17460.00,5238.00,6774.48,14841.0,,8555.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7333.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6774.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13095.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8730.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14841.0,,,percent of total billed charges,,,7857.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM PTC LONG FLEX SZ2B,10451612,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17460.00,5238.00,7333.20,14841.0,,8555.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7333.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8806.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13095.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8730.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13095.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14841.0,,,percent of total billed charges,,,8031.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB REVISION SZ2 15MM,10451613,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,26991.00,8097.30,10472.51,22942.35,,13225.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11336.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10472.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11471.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20243.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13495.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22942.35,,,percent of total billed charges,,,12145.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB REVISION SZ2 15MM,10451613,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,26991.00,8097.30,11336.22,22942.35,,13225.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11336.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13614.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11471.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20243.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13495.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20243.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,22942.35,,,percent of total billed charges,,,12415.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SOCK BRACE FRACTURE CUSTOM FIT X_L3995 X_211888,10451699,CDM,0274,RC,L3995,HCPCS,,,,,,inpatient,facility,,,323.00,96.90,125.32,274.55,,,,,,,,,,,,,,,,,,,,125.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.55,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOCK BRACE FRACTURE CUSTOM FIT X_L3995 X_211888,10451699,CDM,0274,RC,L3995,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,24.75,274.55,,,,,,,,35.47,,,fee schedule,,,,,,,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,74.62,,,fee schedule,,,24.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",36.18,,,fee schedule,,,81.47,,,fee schedule,,,,,,,,,35.47,,,fee schedule,,,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to outpatient services ,73.54,,,fee schedule,,,242.25,,,percent of total billed charges,,,35.47,,,fee schedule,,,24.75,,,fee schedule,,,36.18,,,fee schedule,,,161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,35.47,,,fee schedule,,,242.25,,,percent of total billed charges,,,24.75,,,fee schedule,,,36.18,,,fee schedule,,,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,,,,,,,35.47,,,fee schedule,,,,,,,,,,,,,,,35.47,,,fee schedule,,,,,,,,,35.83,,,fee schedule,,,,,,,,
LD INGEVITY AF IS1 7840 45CM,10453200,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2651.00,795.30,1028.59,2253.35,,,,,,,,,,,,,,,,,,,,1028.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2253.35,,,percent of total billed charges,,,1192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LD INGEVITY AF IS1 7840 45CM,10453200,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2651.00,795.30,1126.68,2253.35,,,,,,,,,,,,,service not payable,,,,,,,1337.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2253.35,,,percent of total billed charges,,,1219.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LD INGEVITY AF IS1 7841 52CM,10453201,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2651.00,795.30,1028.59,2253.35,,,,,,,,,,,,,,,,,,,,1028.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2253.35,,,percent of total billed charges,,,1192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LD INGEVITY AF IS1 7841 52CM,10453201,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2651.00,795.30,1126.68,2253.35,,,,,,,,,,,,,service not payable,,,,,,,1337.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2253.35,,,percent of total billed charges,,,1219.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LD INGEVITY AF IS1 7842 59CM,10453202,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2651.00,795.30,1028.59,2253.35,,,,,,,,,,,,,,,,,,,,1028.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2253.35,,,percent of total billed charges,,,1192.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LD INGEVITY AF IS1 7842 59CM,10453202,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2651.00,795.30,1126.68,2253.35,,,,,,,,,,,,,service not payable,,,,,,,1337.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1126.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1988.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1325.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1988.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2253.35,,,percent of total billed charges,,,1219.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PM Interrogation Leadless Device (in person) w/ana,10455072,CDM,0481,RC,93288,CPT,,,,,,outpatient,facility,,,108.00,32.40,33.76,91.80,,45.25,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,33.76,,,fee schedule,,,54.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.90,,,percent of total billed charges,,,,,,,,,81.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.0,,,percent of total billed charges,,,,,,,,,81.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,91.80,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PM Interrogation Leadless Device (in person) w/ana,10455072,CDM,0481,RC,93288,CPT,05741,APC,,,,outpatient,facility,,,108.00,32.40,34.30,82.13,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,75.22,,,fee schedule,,,34.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",36.48,,,fee schedule,,,82.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,74.13,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,34.30,,,fee schedule,,,36.48,,,fee schedule,,,,,,,,,35.76,,,fee schedule,,,,,,,,,34.30,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",36.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,,,,,,,35.76,,,fee schedule,,,,,,,,,36.11,,,fee schedule,,,,,,,,
PM Interrogation Leadless Device (in person) w/ana,10455072,CDM,0481,RC,93288,CPT,488,EAPG,,,,outpatient,facility,,,108.00,32.40,52.57,109.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,93.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,52.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,91.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,100.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert wireless cardiac stimulator for LV pacing,10455205,CDM,0481,RC,0515T,CPT,,,,,,outpatient,facility,,,47313.00,14193.90,5463.36,50947.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,23864.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,35484.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,50947.0,,,case rate,,,,,,,,,35484.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,40216.05,,,percent of total billed charges,,,21763.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Insert wireless cardiac stimulator for LV pacing,10455205,CDM,0481,RC,0515T,CPT,05231,APC,,,,outpatient,facility,,,47313.00,14193.90,21471.18,49437.86,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,45281.58,,,fee schedule,,,,,,,,,21900.60,,,fee schedule,,,49437.86,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,44625.33,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,21900.60,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,21900.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,21685.55,,,fee schedule,,,,,,,,
Insert wireless cardiac stimulator for LV pacing,10455205,CDM,0481,RC,0515T,CPT,86,EAPG,,,,outpatient,facility,,,47313.00,14193.90,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
C. psittaci IgG,10486,CDM,0300,RC,86631,CPT,,,,,,outpatient,facility,,,21.00,6.30,9.66,26.71,,21.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,11.58,,,fee schedule,,,19.18,,,fee schedule,,,24.65,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.47,,,fee schedule,,,11.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11.81,,,fee schedule,,,26.71,,,fee schedule,,,,,,,,,11.58,,,fee schedule,,,,,,,,,15.17,,,fee schedule,,,24.11,,,fee schedule,,,15.75,,,percent of total billed charges,,,11.58,,,fee schedule,,,11.23,,,fee schedule,,,11.81,,,fee schedule,,,17.84,,,fee schedule,,,11.58,,,fee schedule,,,15.75,,,percent of total billed charges,,,11.23,,,fee schedule,,,11.81,,,fee schedule,,,,,,,,,17.85,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,,,,,,,13.0,,,fee schedule,,,11.58,,,fee schedule,,,,,,,,,11.47,,,fee schedule,,,11.58,,,fee schedule,,,,,,,,,11.70,,,fee schedule,,,,,,,,
C. psittaci IgG,10486,CDM,0300,RC,86631,CPT,394,EAPG,,,,outpatient,facility,,,21.00,6.30,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COVID-19 (2019 Novel Coronavirus) by PCR,10501924,CDM,0300,RC,U0002,HCPCS,,,,,,outpatient,facility,,,75.00,22.50,34.5,115.96,,51.31,,,fee schedule,,Paid in addition to outpatient services ,50.28,,,fee schedule,,,51.31,,,fee schedule,,Paid in addition to outpatient services ,107.01,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,106.21,,,fee schedule,,,48.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",51.29,,,fee schedule,,,115.96,,,fee schedule,,,,,,,,,50.28,,,fee schedule,,,,,,,,,66.14,,,fee schedule,,,104.67,,,fee schedule,,,56.25,,,percent of total billed charges,,,50.28,,,fee schedule,,,48.74,,,fee schedule,,,51.29,,,fee schedule,,,77.78,,,fee schedule,,,50.28,,,fee schedule,,,56.25,,,percent of total billed charges,,,48.74,,,fee schedule,,,51.29,,,fee schedule,,,,,,,,,63.75,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,,,,,,,56.44,,,fee schedule,,,50.28,,,fee schedule,,,,,,,,,49.77,,,fee schedule,,,50.28,,,fee schedule,,,,,,,,,50.78,,,fee schedule,,,,,,,,
COVID-19 (2019 Novel Coronavirus) by PCR,10501924,CDM,0300,RC,U0002,HCPCS,396,EAPG,,,,outpatient,facility,,,75.00,22.50,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COVID-19 (2019 Novel Coronavirus) by PCR,10501924,CDM,0300,RC,87635,CPT,,,,,,outpatient,facility,,,115.00,34.50,48.74,115.96,,51.31,,,fee schedule,,Paid in addition to outpatient services ,50.28,,,fee schedule,,,51.31,,,fee schedule,,Paid in addition to outpatient services ,107.01,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,106.21,,,fee schedule,,,48.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",51.29,,,fee schedule,,,115.96,,,fee schedule,,,,,,,,,50.28,,,fee schedule,,,,,,,,,66.14,,,fee schedule,,,104.67,,,fee schedule,,,86.25,,,percent of total billed charges,,,50.28,,,fee schedule,,,48.74,,,fee schedule,,,51.29,,,fee schedule,,,77.78,,,fee schedule,,,50.28,,,fee schedule,,,86.25,,,percent of total billed charges,,,48.74,,,fee schedule,,,51.29,,,fee schedule,,,,,,,,,97.75,,,percent of total billed charges,,,52.90,,,percent of total billed charges,,,,,,,,,56.44,,,fee schedule,,,50.28,,,fee schedule,,,,,,,,,49.77,,,fee schedule,,,50.28,,,fee schedule,,,,,,,,,50.78,,,fee schedule,,,,,,,,
COVID-19 (2019 Novel Coronavirus) by PCR,10501924,CDM,0300,RC,87635,CPT,397,EAPG,,,,outpatient,facility,,,115.00,34.50,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DEFIB DYNAGEN DF4 1 CHMBR,10501931,CDM,0275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,32877.00,9863.10,12756.28,27945.45,,16109.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13808.34,,,percent of total billed charges,,Paid in addition to inpatient services ,12756.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13972.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24657.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16438.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27945.45,,,percent of total billed charges,,,14794.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB DYNAGEN DF4 1 CHMBR,10501931,CDM,0275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,32877.00,9863.10,13808.34,27945.45,,16109.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13808.34,,,percent of total billed charges,,Paid in addition to outpatient services ,16583.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13972.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24657.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16438.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24657.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27945.45,,,percent of total billed charges,,,15123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN PT 46MM 6.5X80MM,10501932,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN PT 46MM 6.5X80MM,10501932,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL SMR UHP 270ML,10501934,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3294.00,988.20,1278.07,2799.90,,,,,,,,,,,,,,,,,,,,1278.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2799.90,,,percent of total billed charges,,,1482.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL SMR UHP 270ML,10501934,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3294.00,988.20,1399.95,2799.90,,,,,,,,,,,,,service not payable,,,,,,,1661.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2799.90,,,percent of total billed charges,,,1515.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL SMR UHP 295ML,10501935,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3294.00,988.20,1278.07,2799.90,,,,,,,,,,,,,,,,,,,,1278.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2799.90,,,percent of total billed charges,,,1482.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL SMR UHP 295ML,10501935,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3294.00,988.20,1399.95,2799.90,,,,,,,,,,,,,service not payable,,,,,,,1661.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2799.90,,,percent of total billed charges,,,1515.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP BRST GEL SMR UHP 320ML,10501936,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3294.00,988.20,1278.07,2799.90,,,,,,,,,,,,,,,,,,,,1278.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2799.90,,,percent of total billed charges,,,1482.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP BRST GEL SMR UHP 320ML,10501936,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3294.00,988.20,1399.95,2799.90,,,,,,,,,,,,,service not payable,,,,,,,1661.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2799.90,,,percent of total billed charges,,,1515.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS WATCHMAN TRUSEAL SNGL CRV,10501938,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS WATCHMAN TRUSEAL SNGL CRV,10501938,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS WATCHMAN TRUSEAL DBL CRV,10501939,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS WATCHMAN TRUSEAL DBL CRV,10501939,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Unlisted Vascuar Surgery,10502318,CDM,0481,RC,37799,CPT,,,,,,outpatient,facility,,,1971.00,591.30,906.66,3666.78,,1971.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,994.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1478.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1478.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1675.35,,,percent of total billed charges,,,906.66,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Unlisted Vascuar Surgery,10502318,CDM,0481,RC,37799,CPT,05181,APC,,,,outpatient,facility,,,1971.00,591.30,568.69,1361.72,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1247.24,,,fee schedule,,,568.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",604.75,,,fee schedule,,,1361.72,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,1229.16,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,568.69,,,fee schedule,,,604.75,,,fee schedule,,,,,,,,,592.89,,,fee schedule,,,,,,,,,568.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",604.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,,,,,,,592.89,,,fee schedule,,,,,,,,,598.80,,,fee schedule,,,,,,,,
Unlisted Vascuar Surgery,10502318,CDM,0481,RC,37799,CPT,78,EAPG,,,,outpatient,facility,,,1971.00,591.30,1971.0,7528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7528.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6399.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1971.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1971.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1971.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3466.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3813.06,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Removal of Pacemaker Generator Only,10502480,CDM,0481,RC,33233,CPT,,,,,,outpatient,facility,,,8524.00,2557.20,3666.78,7245.40,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Removal of Pacemaker Generator Only,10502480,CDM,0481,RC,33233,CPT,05222,APC,,,,outpatient,facility,,,8524.00,2557.20,7612.46,18227.89,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16695.46,,,fee schedule,,,7612.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8095.12,,,fee schedule,,,18227.89,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16453.50,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,7612.46,,,fee schedule,,,8095.12,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,7612.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",8095.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,8015.43,,,fee schedule,,,,,,,,
Removal of Pacemaker Generator Only,10502480,CDM,0481,RC,33233,CPT,87,EAPG,,,,outpatient,facility,,,8524.00,2557.20,8524.0,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8524.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8524.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8524.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CAN PT 46MM 6.5X105MM,10502485,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,942.00,282.60,365.50,800.70,,,,,,,,,,,,,,,,,,,,365.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.70,,,percent of total billed charges,,,423.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN PT 46MM 6.5X105MM,10502485,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,942.00,282.60,400.35,800.70,,,,,,,,,,,,,service not payable,,,,,,,475.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,400.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,706.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,471.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,706.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,800.70,,,percent of total billed charges,,,433.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRI X3 ECC 36MM ID,10502486,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5550.00,1665.00,2153.40,4717.5,,2719.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2331.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2153.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2358.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4162.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2775.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4717.5,,,percent of total billed charges,,,2497.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRI X3 ECC 36MM ID,10502486,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5550.00,1665.00,2331.0,4717.5,,2719.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2331.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2799.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2358.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4162.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2775.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4162.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4717.5,,,percent of total billed charges,,,2553.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 2.0 X 8MM,10502487,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 2.0 X 8MM,10502487,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MICRA DUAL CHAMBER TPS,10502488,CDM,0275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,53107.00,15932.10,20605.52,45140.95,,26022.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22304.94,,,percent of total billed charges,,Paid in addition to inpatient services ,20605.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22570.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,39830.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45140.95,,,percent of total billed charges,,,23898.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MICRA DUAL CHAMBER TPS,10502488,CDM,0275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,53107.00,15932.10,22304.94,45140.95,,26022.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22304.94,,,percent of total billed charges,,Paid in addition to outpatient services ,26787.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,22570.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,39830.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,26553.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,39830.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,45140.95,,,percent of total billed charges,,,24429.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FORTE PT 4.0X40MM,10502491,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FORTE PT 4.0X40MM,10502491,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE FIXED .035X80CM,10502498,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.13,140.25,,101.97,,,percent of total billed charges,,,,,,,,service not payable,80.52,,,percent of total billed charges,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.13,,,percent of total billed charges,,,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,107.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Revascularization Fem Pop w/Stent Placement,10502575,CDM,0481,RC,37226,CPT,,,,,,outpatient,facility,,,30597.00,9179.10,5463.36,26007.45,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,15433.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26007.45,,,percent of total billed charges,,,14074.62,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Revascularization Fem Pop w/Stent Placement,10502575,CDM,0481,RC,37226,CPT,05193,APC,,,,outpatient,facility,,,30597.00,9179.10,10431.35,24977.68,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22877.78,,,fee schedule,,,10431.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11081.84,,,fee schedule,,,24977.68,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22546.22,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,10431.35,,,fee schedule,,,11081.84,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10431.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",11081.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10972.86,,,fee schedule,,,,,,,,
Revascularization Fem Pop w/Stent Placement,10502575,CDM,0481,RC,37226,CPT,85,EAPG,,,,outpatient,facility,,,30597.00,9179.10,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Revascularization w/Atherectomy Tibial Artery,10502576,CDM,0481,RC,37229,CPT,,,,,,outpatient,facility,,,30597.00,9179.10,5463.36,26007.45,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,15433.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26007.45,,,percent of total billed charges,,,14074.62,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Revascularization w/Atherectomy Tibial Artery,10502576,CDM,0481,RC,37229,CPT,05194,APC,,,,outpatient,facility,,,30597.00,9179.10,16517.06,39549.77,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,36224.79,,,fee schedule,,,16517.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17527.09,,,fee schedule,,,39549.77,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,35699.80,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,16517.06,,,fee schedule,,,17527.09,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,16517.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",17527.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,17354.92,,,fee schedule,,,,,,,,
Revascularization w/Atherectomy Tibial Artery,10502576,CDM,0481,RC,37229,CPT,85,EAPG,,,,outpatient,facility,,,30597.00,9179.10,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert tunneled centrally inserted CV cath  w/o po,10503001,CDM,0450,RC,36558,CPT,,,,,,outpatient,facility,,,7328.00,2198.40,774.0,6228.80,,4528.70,,,percent of total billed charges,,,,,,,,,3576.06,,,percent of total billed charges,,,3696.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5496.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5496.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6228.80,,,percent of total billed charges,,,3370.88,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert tunneled centrally inserted CV cath  w/o po,10503001,CDM,0450,RC,36558,CPT,05183,APC,,,,outpatient,facility,,,7328.00,2198.40,1447.58,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,1447.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,1447.58,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,1447.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Insert tunneled centrally inserted CV cath  w/o po,10503001,CDM,0450,RC,36558,CPT,83,EAPG,,,,outpatient,facility,,,7328.00,2198.40,3082.81,8961.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7617.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3891.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4280.91,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM REV 18 X 110MM,10503058,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REV 18 X 110MM,10503058,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGEMNT REV FEM POST SZ7 4MM,10503059,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGEMNT REV FEM POST SZ7 4MM,10503059,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CPM 11.5MMX38CM 130D,10503060,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CPM 11.5MMX38CM 130D,10503060,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTCL Z NAIL 5.0X55MM,10503061,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTCL Z NAIL 5.0X55MM,10503061,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM REV 16 X 110MM,10503062,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REV 16 X 110MM,10503062,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INGL ANSR IMPCT DSTL PSTNR 11,10503346,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INGL ANSR IMPCT DSTL PSTNR 11,10503346,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACET ENDO II 45MM,10503347,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACET ENDO II 45MM,10503347,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO FX 11MM,10503348,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO FX 11MM,10503348,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EDEMAWEAR - SMALL (BULK),10503349,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EDEMAWEAR - SMALL (BULK),10503349,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT HEAD HIP 50MM,10503351,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT HEAD HIP 50MM,10503351,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAPTER TAPER 0MM NECK,10503352,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADAPTER TAPER 0MM NECK,10503352,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 12X144MM,10503353,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 12X144MM,10503353,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PT 11 Mix 1 Hr Incubation,10503440,CDM,0300,RC,85611,CPT,,,,,XU  ,outpatient,facility,,,40.00,12.00,3.74,34.0,,16.74,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,3.86,,,fee schedule,,,12.49,,,fee schedule,,,8.22,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,8.16,,,fee schedule,,,3.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3.94,,,fee schedule,,,8.90,,,fee schedule,,,,,,,,,3.86,,,fee schedule,,,,,,,,,5.05,,,fee schedule,,,8.04,,,fee schedule,,,30.0,,,percent of total billed charges,,,3.86,,,fee schedule,,,3.74,,,fee schedule,,,3.94,,,fee schedule,,,5.94,,,fee schedule,,,3.86,,,fee schedule,,,30.0,,,percent of total billed charges,,,,,,,,,3.94,,,fee schedule,,,,,,,,,34.0,,,percent of total billed charges,,,18.40,,,percent of total billed charges,,,,,,,,,4.33,,,fee schedule,,,3.86,,,fee schedule,,,,,,,,,3.82,,,fee schedule,,,3.86,,,fee schedule,,,,,,,,,3.90,,,fee schedule,,,,,,,,
PT 11 Mix 1 Hr Incubation,10503440,CDM,0300,RC,85611,CPT,406,EAPG,,,XU  ,outpatient,facility,,,40.00,12.00,5.24,36.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,30.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,24.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,27.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PTT 11 Mix 1 Hr Incubation,10503441,CDM,0300,RC,85732,CPT,,,,,XU  ,outpatient,facility,,,54.00,16.20,6.15,45.90,,27.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.34,,,fee schedule,,,20.53,,,fee schedule,,,13.49,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.39,,,fee schedule,,,6.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.47,,,fee schedule,,,14.62,,,fee schedule,,,,,,,,,6.34,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.20,,,fee schedule,,,40.5,,,percent of total billed charges,,,6.34,,,fee schedule,,,6.15,,,fee schedule,,,6.47,,,fee schedule,,,9.92,,,fee schedule,,,6.34,,,fee schedule,,,40.5,,,percent of total billed charges,,,,,,,,,6.47,,,fee schedule,,,,,,,,,45.90,,,percent of total billed charges,,,24.84,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.40,,,fee schedule,,,,,,,,
PTT 11 Mix 1 Hr Incubation,10503441,CDM,0300,RC,85732,CPT,406,EAPG,,,XU  ,outpatient,facility,,,54.00,16.20,5.24,36.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,30.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,24.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,27.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PTT 11 Mix 1 Hr Incubation,10503442,CDM,0300,RC,85732,CPT,,,,,XU  ,outpatient,facility,,,54.00,16.20,6.15,45.90,,27.51,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.34,,,fee schedule,,,20.53,,,fee schedule,,,13.49,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.39,,,fee schedule,,,6.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.47,,,fee schedule,,,14.62,,,fee schedule,,,,,,,,,6.34,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.20,,,fee schedule,,,40.5,,,percent of total billed charges,,,6.34,,,fee schedule,,,6.15,,,fee schedule,,,6.47,,,fee schedule,,,9.92,,,fee schedule,,,6.34,,,fee schedule,,,40.5,,,percent of total billed charges,,,,,,,,,6.47,,,fee schedule,,,,,,,,,45.90,,,percent of total billed charges,,,24.84,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.28,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,6.40,,,fee schedule,,,,,,,,
PTT 11 Mix 1 Hr Incubation,10503442,CDM,0300,RC,85732,CPT,406,EAPG,,,XU  ,outpatient,facility,,,54.00,16.20,5.24,36.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,30.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,24.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,27.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Biopsy cervix single or mult or exc of lesion w,10503960,CDM,0450,RC,57500,CPT,,,,,,outpatient,facility,,,2022.00,606.60,774.0,1718.7,,1249.60,,,percent of total billed charges,,,,,,,,,986.74,,,percent of total billed charges,,,1019.9,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1718.7,,,percent of total billed charges,,,930.12,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Biopsy cervix single or mult or exc of lesion w,10503960,CDM,0450,RC,57500,CPT,05413,APC,,,,outpatient,facility,,,2022.00,606.60,400.46,1917.81,,,,,,,,835.01,,,fee schedule,,,,,,,,,,,,,,,1756.58,,,fee schedule,,,400.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",851.71,,,fee schedule,,,1917.81,,,fee schedule,,,,,,,,,835.01,,,fee schedule,,,,,,,,,,,,,,,1731.12,,,fee schedule,,,,,,,,,835.01,,,fee schedule,,,400.46,,,fee schedule,,,851.71,,,fee schedule,,,,,,,,,835.01,,,fee schedule,,,,,,,,,400.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",851.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,835.01,,,fee schedule,,,,,,,,,,,,,,,835.01,,,fee schedule,,,,,,,,,843.33,,,fee schedule,,,,,,,,
Biopsy cervix single or mult or exc of lesion w,10503960,CDM,0450,RC,57500,CPT,209,EAPG,,,,outpatient,facility,,,2022.00,606.60,633.64,2359.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2359.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2005.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,773.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,773.60,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,633.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,697.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ENDOGRAFT MAIN BODY 22X13X40MM,10504439,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,32780.00,9834.00,12718.64,27863.0,,16062.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13767.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12718.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13931.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24585.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16390.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27863.0,,,percent of total billed charges,,,14751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDOGRAFT MAIN BODY 22X13X40MM,10504439,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,32780.00,9834.00,13767.6,27863.0,,16062.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13767.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16534.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13931.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24585.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16390.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24585.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27863.0,,,percent of total billed charges,,,15078.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ILIAC LIMB PMA 14 10 80,10504440,CDM,0278,RC,C1727,HCPCS,,,,,,inpatient,facility,,,18683.00,5604.90,7249.00,15880.55,,9154.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7846.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7249.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7940.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14012.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15880.55,,,percent of total billed charges,,,8407.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ILIAC LIMB PMA 14 10 80,10504440,CDM,0278,RC,C1727,HCPCS,,,,,,outpatient,facility,,,18683.00,5604.90,7846.86,15880.55,,9154.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7846.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9423.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7940.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14012.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14012.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15880.55,,,percent of total billed charges,,,8594.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 6X200MM,10504441,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 6X200MM,10504441,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 7X200MM,10504442,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 7X200MM,10504442,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON EVERCROSS 6X200X135,10504443,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,522.75,1045.5,,760.14,,,percent of total billed charges,,,,,,,,service not payable,600.24,,,percent of total billed charges,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,522.75,,,percent of total billed charges,,,,,,,,,922.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,922.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON NANOCROSS 4X40X150,10504444,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1897.00,569.10,806.23,1612.45,,1172.35,,,percent of total billed charges,,,,,,,,service not payable,925.74,,,percent of total billed charges,,,956.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,806.23,,,percent of total billed charges,,,,,,,,,1422.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,948.5,,,percent of total billed charges,,,,,,,,service not payable,1422.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1612.45,,,percent of total billed charges,,,872.62,,,percent of total billed charges,,,,,,,,,1233.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1233.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER BALLOON PTA 2.5X210MM,10504445,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,1452.3,,,percent of total billed charges,,,,,,,,service not payable,1146.8,,,percent of total billed charges,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON IN.PACT ADMIRAL 6X250,10504446,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3135.22,6270.45,,4558.99,,,percent of total billed charges,,,,,,,,service not payable,3599.98,,,percent of total billed charges,,,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,4795.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4795.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON IN.PACT ADMIRAL 4X200,10504447,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6705.00,2011.50,2849.63,5699.25,,4143.69,,,percent of total billed charges,,,,,,,,service not payable,3272.04,,,percent of total billed charges,,,3382.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2849.63,,,percent of total billed charges,,,,,,,,,5028.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3352.5,,,percent of total billed charges,,,,,,,,service not payable,5028.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5699.25,,,percent of total billed charges,,,3084.30,,,percent of total billed charges,,,,,,,,,4358.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4358.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING INCONTINENCE SZ 1,10504449,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,228.00,68.40,88.46,193.80,,,,,,,,,,,,,,,,,,,,88.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.80,,,percent of total billed charges,,,102.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING INCONTINENCE SZ 1,10504449,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,228.00,68.40,96.90,193.80,,,,,,,,,,,,,service not payable,,,,,,,115.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,171.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,193.80,,,percent of total billed charges,,,104.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING INCONTINENCE SZ 2,10504450,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,228.00,68.40,88.46,193.80,,,,,,,,,,,,,,,,,,,,88.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.80,,,percent of total billed charges,,,102.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING INCONTINENCE SZ 2,10504450,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,228.00,68.40,96.90,193.80,,,,,,,,,,,,,service not payable,,,,,,,115.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,171.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,193.80,,,percent of total billed charges,,,104.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING INCONTINENCE SZ 3,10504451,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,228.00,68.40,88.46,193.80,,,,,,,,,,,,,,,,,,,,88.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.80,,,percent of total billed charges,,,102.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING INCONTINENCE SZ 3,10504451,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,228.00,68.40,96.90,193.80,,,,,,,,,,,,,service not payable,,,,,,,115.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,171.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,193.80,,,percent of total billed charges,,,104.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH RX 140 CM LRG LUMEN,10504452,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,6361.00,1908.30,2703.43,5406.85,,3931.10,,,percent of total billed charges,,,,,,,,service not payable,3104.17,,,percent of total billed charges,,,3208.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2703.43,,,percent of total billed charges,,,,,,,,,4770.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3180.5,,,percent of total billed charges,,,,,,,,service not payable,4770.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5406.85,,,percent of total billed charges,,,2926.06,,,percent of total billed charges,,,,,,,,,4134.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4134.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Six Minute Walk 94618 - RT Only Oxygen Therapy Pro,10504692,CDM,0460,RC,94618,CPT,,,,,,outpatient,facility,,,328.00,98.40,139.40,983.0,,202.70,,,percent of total billed charges,,,,,,,,,160.06,,,percent of total billed charges,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Six Minute Walk 94618 - RT Only Oxygen Therapy Pro,10504692,CDM,0460,RC,94618,CPT,05734,APC,,,,outpatient,facility,,,328.00,98.40,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Six Minute Walk 94618 - RT Only Oxygen Therapy Pro,10504692,CDM,0460,RC,94618,CPT,412,EAPG,,,,outpatient,facility,,,328.00,98.40,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Aerosol Inhalation Pentamidine 94642 - Aerosol Th,10504695,CDM,0410,RC,94642,CPT,,,,,,outpatient,facility,,,586.00,175.80,205.0,498.10,,362.15,,,percent of total billed charges,,,,,,,,,285.97,,,percent of total billed charges,,,295.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.05,,,percent of total billed charges,,,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.0,,,percent of total billed charges,,,,,,,,,439.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,498.10,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Aerosol Inhalation Pentamidine 94642 - Aerosol Th,10504695,CDM,0410,RC,94642,CPT,05791,APC,,,,outpatient,facility,,,586.00,175.80,187.09,447.98,,,,,,,,195.05,,,fee schedule,,,,,,,,,,,,,,,410.32,,,fee schedule,,,187.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",198.95,,,fee schedule,,,447.98,,,fee schedule,,,,,,,,,195.05,,,fee schedule,,,,,,,,,,,,,,,404.37,,,fee schedule,,,,,,,,,195.05,,,fee schedule,,,187.09,,,fee schedule,,,198.95,,,fee schedule,,,,,,,,,195.05,,,fee schedule,,,,,,,,,187.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",198.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.05,,,fee schedule,,,,,,,,,,,,,,,195.05,,,fee schedule,,,,,,,,,196.99,,,fee schedule,,,,,,,,
Aerosol Inhalation Pentamidine 94642 - Aerosol Th,10504695,CDM,0410,RC,94642,CPT,412,EAPG,,,,outpatient,facility,,,586.00,175.80,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Peak Flow Measurement 94010 - Incentive Spiro RT P,10504698,CDM,0460,RC,94010,CPT,,,,,,outpatient,facility,,,274.00,82.20,116.45,983.0,,169.33,,,percent of total billed charges,,,,,,,,,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.0,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Peak Flow Measurement 94010 - Incentive Spiro RT P,10504698,CDM,0460,RC,94010,CPT,05721,APC,,,,outpatient,facility,,,274.00,82.20,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Peak Flow Measurement 94010 - Incentive Spiro RT P,10504698,CDM,0460,RC,94010,CPT,412,EAPG,,,,outpatient,facility,,,274.00,82.20,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Flutter Device- Initial - Bronchial Hygiene Proced,10504709,CDM,0410,RC,94667,CPT,,,,,,outpatient,facility,,,440.00,132.00,187.0,374.0,,271.92,,,percent of total billed charges,,,,,,,,,214.72,,,percent of total billed charges,,,221.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,,,,,,,,330.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.0,,,percent of total billed charges,,,,,,,,,330.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,374.0,,,percent of total billed charges,,,202.40,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Flutter Device- Initial - Bronchial Hygiene Proced,10504709,CDM,0410,RC,94667,CPT,05734,APC,,,,outpatient,facility,,,440.00,132.00,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Flutter Device- Initial - Bronchial Hygiene Proced,10504709,CDM,0410,RC,94667,CPT,412,EAPG,,,,outpatient,facility,,,440.00,132.00,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Percussion/Postural Drainage-Subsequent - Bronchia,10504710,CDM,0410,RC,94668,CPT,,,,,,outpatient,facility,,,173.00,51.90,73.53,233.0,,106.91,,,percent of total billed charges,,,,,,,,,84.42,,,percent of total billed charges,,,87.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.53,,,percent of total billed charges,,,,,,,,,129.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.5,,,percent of total billed charges,,,,,,,,,129.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Percussion/Postural Drainage-Subsequent - Bronchia,10504710,CDM,0410,RC,94668,CPT,05734,APC,,,,outpatient,facility,,,173.00,51.90,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Percussion/Postural Drainage-Subsequent - Bronchia,10504710,CDM,0410,RC,94668,CPT,412,EAPG,,,,outpatient,facility,,,173.00,51.90,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Percussion/Postural Drainage-Initial - Bronchial H,10504711,CDM,0410,RC,94667,CPT,,,,,,outpatient,facility,,,191.00,57.30,81.17,233.0,,118.04,,,percent of total billed charges,,,,,,,,,93.21,,,percent of total billed charges,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Percussion/Postural Drainage-Initial - Bronchial H,10504711,CDM,0410,RC,94667,CPT,05734,APC,,,,outpatient,facility,,,191.00,57.30,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Percussion/Postural Drainage-Initial - Bronchial H,10504711,CDM,0410,RC,94667,CPT,412,EAPG,,,,outpatient,facility,,,191.00,57.30,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Flutter Device- Subsequent - Bronchial Hygiene Pro,10504712,CDM,0410,RC,94668,CPT,,,,,,outpatient,facility,,,173.00,51.90,73.53,233.0,,106.91,,,percent of total billed charges,,,,,,,,,84.42,,,percent of total billed charges,,,87.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.53,,,percent of total billed charges,,,,,,,,,129.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.5,,,percent of total billed charges,,,,,,,,,129.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Flutter Device- Subsequent - Bronchial Hygiene Pro,10504712,CDM,0410,RC,94668,CPT,05734,APC,,,,outpatient,facility,,,173.00,51.90,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Flutter Device- Subsequent - Bronchial Hygiene Pro,10504712,CDM,0410,RC,94668,CPT,412,EAPG,,,,outpatient,facility,,,173.00,51.90,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tray Foley 16 FR W/Stat LK 2L X_899916 X_331284 -,10504802,CDM,0274,RC,A4315,HCPCS,,,,,,inpatient,facility,,,76.00,22.80,29.49,64.60,,,,,,,,,,,,,,,,,,,,29.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,57.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.60,,,percent of total billed charges,,,34.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Tray Foley 16 FR W/Stat LK 2L X_899916 X_331284 -,10504802,CDM,0274,RC,A4315,HCPCS,,,,,,outpatient,facility,,,76.00,22.80,32.30,64.60,,,,,,,,,,,,,service not payable,,,,,,,38.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,32.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,57.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,38.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,57.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,64.60,,,percent of total billed charges,,,34.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Robinson Cath 324713 - Misc. Labor Charges,10504807,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,31.00,9.30,13.18,26.35,,19.16,,,percent of total billed charges,,,,,,,,service not payable,15.13,,,percent of total billed charges,,,15.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13.18,,,percent of total billed charges,,,,,,,,,23.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15.5,,,percent of total billed charges,,,,,,,,service not payable,23.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26.35,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,20.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,20.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Foley Cath w/Meter 331287 - Misc. Labor Charges,10504811,CDM,0274,RC,A4315,HCPCS,,,,,,inpatient,facility,,,92.00,27.60,35.70,78.20,,,,,,,,,,,,,,,,,,,,35.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,69.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.20,,,percent of total billed charges,,,41.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Foley Cath w/Meter 331287 - Misc. Labor Charges,10504811,CDM,0274,RC,A4315,HCPCS,,,,,,outpatient,facility,,,92.00,27.60,39.10,78.20,,,,,,,,,,,,,service not payable,,,,,,,46.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,39.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,69.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,46.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,69.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,78.20,,,percent of total billed charges,,,42.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ultrasound Level 1 Diagnostic/Screening - Labor Pr,10504863,CDM,0402,RC,76805,CPT,,,,,,outpatient,facility,,,840.00,252.00,195.67,714.0,,262.24,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,195.67,,,fee schedule,,,423.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,420.0,,,percent of total billed charges,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,230.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Ultrasound Level 1 Diagnostic/Screening - Labor Pr,10504863,CDM,0402,RC,76805,CPT,05522,APC,,,,outpatient,facility,,,840.00,252.00,97.82,234.20,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,214.51,,,fee schedule,,,97.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,211.41,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,97.82,,,fee schedule,,,104.01,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,97.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",104.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,102.99,,,fee schedule,,,,,,,,
Ultrasound Level 1 Diagnostic/Screening - Labor Pr,10504863,CDM,0402,RC,76805,CPT,470,EAPG,,,,outpatient,facility,,,840.00,252.00,146.52,302.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,257.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,146.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,146.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,223.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,246.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
External Version - Labor Procedure Charge,10504864,CDM,0360,RC,59412,CPT,,,,,,outpatient,facility,,,5078.00,1523.40,2335.88,5076.0,,3138.20,,,percent of total billed charges,,,,,,,,,2478.06,,,percent of total billed charges,,,2561.34,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,3808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,3808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4316.30,,,percent of total billed charges,,,2335.88,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
External Version - Labor Procedure Charge,10504864,CDM,0360,RC,59412,CPT,05414,APC,,,,outpatient,facility,,,5078.00,1523.40,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
External Version - Labor Procedure Charge,10504864,CDM,0360,RC,59412,CPT,178,EAPG,,,,outpatient,facility,,,5078.00,1523.40,839.36,3680.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3421.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2908.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,839.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,839.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3346.14,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3680.75,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Yes - Ultrasound Level 1 Diag/Screen Charge,10504914,CDM,0402,RC,76805,CPT,,,,,,outpatient,facility,,,840.00,252.00,195.67,714.0,,262.24,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,195.67,,,fee schedule,,,423.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.0,,,percent of total billed charges,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,420.0,,,percent of total billed charges,,,,,,,,,630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,714.0,,,percent of total billed charges,,,386.40,,,percent of total billed charges,,,,,,,,,230.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Yes - Ultrasound Level 1 Diag/Screen Charge,10504914,CDM,0402,RC,76805,CPT,05522,APC,,,,outpatient,facility,,,840.00,252.00,97.82,234.20,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,214.51,,,fee schedule,,,97.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",104.01,,,fee schedule,,,234.20,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,211.41,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,97.82,,,fee schedule,,,104.01,,,fee schedule,,,,,,,,,101.97,,,fee schedule,,,,,,,,,97.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",104.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,,,,,,,101.97,,,fee schedule,,,,,,,,,102.99,,,fee schedule,,,,,,,,
Yes - Ultrasound Level 1 Diag/Screen Charge,10504914,CDM,0402,RC,76805,CPT,470,EAPG,,,,outpatient,facility,,,840.00,252.00,146.52,302.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,257.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,146.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,146.52,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,223.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,246.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MOD SED OVER 5 FIRST 15 M,10504980,CDM,0379,RC,99152,CPT,,,,,,outpatient,facility,,,133.00,39.90,56.52,113.05,,82.19,,,percent of total billed charges,,,,,,,,service not payable,64.90,,,percent of total billed charges,,,67.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,56.52,,,percent of total billed charges,,,,,,,,,99.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,,,service not payable,99.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,113.05,,,percent of total billed charges,,,61.18,,,percent of total billed charges,,,,,,,,,86.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,86.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MOD SED OVER 5 FIRST 15 M,10504980,CDM,0379,RC,99152,CPT,380,EAPG,,,,outpatient,facility,,,133.00,39.90,33.12,65.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,48.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MOD SEDATION ADD 15 MIN,10504984,CDM,0379,RC,99153,CPT,,,,,,outpatient,facility,,,91.00,27.30,38.67,77.35,,56.24,,,percent of total billed charges,,,,,,,,service not payable,44.41,,,percent of total billed charges,,,45.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,38.67,,,percent of total billed charges,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,68.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,77.35,,,percent of total billed charges,,,41.86,,,percent of total billed charges,,,,,,,,,59.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,59.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MOD SEDATION ADD 15 MIN,10504984,CDM,0379,RC,99153,CPT,380,EAPG,,,,outpatient,facility,,,91.00,27.30,33.12,65.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,48.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MOD SED 2NDPERSON ADD 15M,10504999,CDM,0379,RC,99157,CPT,,,,,,outpatient,facility,,,280.00,84.00,119.0,238.0,,173.04,,,percent of total billed charges,,,,,,,,service not payable,136.64,,,percent of total billed charges,,,141.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,,,,,,,,210.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,140.0,,,percent of total billed charges,,,,,,,,service not payable,210.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,238.0,,,percent of total billed charges,,,128.80,,,percent of total billed charges,,,,,,,,,182.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,182.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MOD SED 2NDPERSON ADD 15M,10504999,CDM,0379,RC,99157,CPT,380,EAPG,,,,outpatient,facility,,,280.00,84.00,33.12,65.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,48.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
IandD ABSC COMPL OR MULTIPL,10505007,CDM,0361,RC,10061,CPT,,,,,,outpatient,facility,,,496.00,148.80,228.16,2912.34,,496.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,250.18,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,372.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,372.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,421.60,,,percent of total billed charges,,,228.16,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
IandD ABSC COMPL OR MULTIPL,10505007,CDM,0361,RC,10061,CPT,05052,APC,,,,outpatient,facility,,,496.00,148.80,367.5,879.98,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,806.00,,,fee schedule,,,367.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",390.80,,,fee schedule,,,879.98,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,794.31,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,367.5,,,fee schedule,,,390.80,,,fee schedule,,,,,,,,,383.14,,,fee schedule,,,,,,,,,367.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",390.80,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,,,,,,,383.14,,,fee schedule,,,,,,,,,386.95,,,fee schedule,,,,,,,,
IandD ABSC COMPL OR MULTIPL,10505007,CDM,0361,RC,10061,CPT,3,EAPG,,,,outpatient,facility,,,496.00,148.80,240.16,1847.0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1847.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1569.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,268.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DX BONE MARROW BXASPIRA,10505011,CDM,0361,RC,38222,CPT,,,,,,outpatient,facility,,,4112.00,1233.60,1891.52,3795.64,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,2074.09,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3084.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3084.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3495.20,,,percent of total billed charges,,,1891.52,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
DX BONE MARROW BXASPIRA,10505011,CDM,0361,RC,38222,CPT,05073,APC,,,,outpatient,facility,,,4112.00,1233.60,2632.59,6303.68,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5773.73,,,fee schedule,,,2632.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2799.5,,,fee schedule,,,6303.68,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,5690.05,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,2632.59,,,fee schedule,,,2799.5,,,fee schedule,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2632.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2799.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,,,,,,,2744.61,,,fee schedule,,,,,,,,,2771.94,,,fee schedule,,,,,,,,
DX BONE MARROW BXASPIRA,10505011,CDM,0361,RC,38222,CPT,124,EAPG,,,,outpatient,facility,,,4112.00,1233.60,1513.42,6811.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6811.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5789.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2410.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1513.42,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1664.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BALLOON NANOCROSS 3X80X150,10505345,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1897.00,569.10,806.23,1612.45,,1172.35,,,percent of total billed charges,,,,,,,,service not payable,925.74,,,percent of total billed charges,,,956.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,806.23,,,percent of total billed charges,,,,,,,,,1422.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,948.5,,,percent of total billed charges,,,,,,,,service not payable,1422.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1612.45,,,percent of total billed charges,,,872.62,,,percent of total billed charges,,,,,,,,,1233.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1233.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB SPLINED V2 18X80MM,10505354,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5522.00,1656.60,2142.54,4693.70,,2705.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2319.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2142.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2346.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4141.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2761.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4693.70,,,percent of total billed charges,,,2484.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB SPLINED V2 18X80MM,10505354,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5522.00,1656.60,2319.24,4693.70,,2705.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2319.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2785.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2346.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4141.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2761.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4141.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4693.70,,,percent of total billed charges,,,2540.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INJ PRO SACROILISC JNT,10505500,CDM,0361,RC,27096,CPT,,,,,,outpatient,facility,,,1189.00,356.70,546.94,2912.34,,1189.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,599.73,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,891.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,891.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1010.65,,,percent of total billed charges,,,546.94,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INJ PRO SACROILISC JNT,10505500,CDM,0361,RC,27096,CPT,50,EAPG,,,,outpatient,facility,,,1189.00,356.70,667.58,1797.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1527.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,667.58,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,667.58,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,667.58,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,868.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,954.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INJ PRO SACROILISC JNT,10505500,CDM,0510,RC,G0260,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,194.12,358.70,,260.80,,,percent of total billed charges,,,,,,,,,205.94,,,percent of total billed charges,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,274.30,,,percent of total billed charges,,,,,,,,,,,,,,,274.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
INJ PRO SACROILISC JNT,10505500,CDM,0510,RC,G0260,HCPCS,05442,APC,,,,outpatient,facility,,,422.00,126.60,422.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,422.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,422.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
INJ PRO SACROILISC JNT,10505500,CDM,0510,RC,G0260,HCPCS,50,EAPG,,,,outpatient,facility,,,422.00,126.60,868.0,1797.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1527.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,954.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BIL INJ PRO SACROILISC JT,10505504,CDM,0361,RC,27096,CPT,,,,,50  ,outpatient,facility,,,2377.00,713.10,1093.42,4368.51,,2377.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,4368.51,,,case rate,,,1198.96,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1659.0,,,case rate,,,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1951.5,,,case rate,,,,,,,,service not payable,1782.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,,1093.42,,,percent of total billed charges,,,,,,,,,2662.5,,,case rate,,,,,,,,service not payable,,,,,,,2343.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIL INJ PRO SACROILISC JT,10505504,CDM,0361,RC,27096,CPT,50,EAPG,,,50  ,outpatient,facility,,,2377.00,713.10,1001.37,2696.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2696.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2291.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.37,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1001.37,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1001.37,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1302.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1432.2,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BIL INJ PRO SACROILISC JT,10505504,CDM,0510,RC,G0259,HCPCS,,,,,,outpatient,facility,,,327.00,98.10,150.42,277.95,,202.09,,,percent of total billed charges,,,,,,,,service not payable,159.58,,,percent of total billed charges,,,164.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,245.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,277.95,,,percent of total billed charges,,,150.42,,,percent of total billed charges,,,,,,,,,212.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,212.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIL INJ PRO SACROILISC JT,10505504,CDM,0510,RC,G0259,HCPCS,50,EAPG,,,,outpatient,facility,,,327.00,98.10,868.0,1797.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1527.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,954.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DandC DIAG and/OR THERAPEUTIC,10505579,CDM,0361,RC,58120,CPT,,,,,,outpatient,facility,,,8798.00,2639.40,3666.78,7478.30,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,4437.71,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,6598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,6598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7478.30,,,percent of total billed charges,,,4047.08,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
DandC DIAG and/OR THERAPEUTIC,10505579,CDM,0361,RC,58120,CPT,05414,APC,,,,outpatient,facility,,,8798.00,2639.40,2924.61,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,2924.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,2924.61,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,2924.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
DandC DIAG and/OR THERAPEUTIC,10505579,CDM,0361,RC,58120,CPT,207,EAPG,,,,outpatient,facility,,,8798.00,2639.40,3381.34,8501.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8501.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7226.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3381.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3381.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3381.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4681.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5149.10,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Vasc Embolization/Occlusion for hemorrhage,10506153,CDM,0481,RC,37244,CPT,,,,,,outpatient,facility,,,31874.00,9562.20,4917.20,27092.90,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,16077.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,23905.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,23905.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27092.90,,,percent of total billed charges,,,14662.04,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Vasc Embolization/Occlusion for hemorrhage,10506153,CDM,0481,RC,37244,CPT,05193,APC,,,,outpatient,facility,,,31874.00,9562.20,10431.35,24977.68,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22877.78,,,fee schedule,,,10431.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11081.84,,,fee schedule,,,24977.68,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22546.22,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,10431.35,,,fee schedule,,,11081.84,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10431.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",11081.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10972.86,,,fee schedule,,,,,,,,
Vasc Embolization/Occlusion for hemorrhage,10506153,CDM,0481,RC,37244,CPT,85,EAPG,,,,outpatient,facility,,,31874.00,9562.20,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Reposition Transvenous pacemaker/defibrillator ele,10506154,CDM,0481,RC,33215,CPT,,,,,,outpatient,facility,,,3443.00,1032.90,1583.78,6509.0,,3443.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Reposition Transvenous pacemaker/defibrillator ele,10506154,CDM,0481,RC,33215,CPT,05183,APC,,,,outpatient,facility,,,3443.00,1032.90,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Reposition Transvenous pacemaker/defibrillator ele,10506154,CDM,0481,RC,33215,CPT,74,EAPG,,,,outpatient,facility,,,3443.00,1032.90,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DM-Medical Nutrition Therapy Group Each 30 Minut,10506409,CDM,0942,RC,97804,CPT,,,,,,outpatient,facility,,,49.00,14.70,12.99,312.0,,30.28,,,percent of total billed charges,,,13.01,,,fee schedule,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.49,,,fee schedule,,,,,,,,service not payable,13.25,,,fee schedule,,,29.97,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,,,,,,,20.82,,,percent of total billed charges,,,27.09,,,fee schedule,,,36.75,,,percent of total billed charges,,,13.01,,,fee schedule,,,,,,,,service not payable,13.27,,,fee schedule,,,24.5,,,percent of total billed charges,,,12.99,,,fee schedule,,,36.75,,,percent of total billed charges,,,,,,,,service not payable,13.27,,,fee schedule,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,312.0,,,per diem,,,12.99,,,fee schedule,,,,,,,,,275.0,,,per diem,,,13.01,,,fee schedule,,,,,,,,,13.01,,,fee schedule,,,,,,,,
DM-Medical Nutrition Therapy Group Each 30 Minut,10506409,CDM,0942,RC,97804,CPT,118,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,404.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,344.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,120.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DM-Medical Nutrition Therapy Group Each 30 Minut,10506409,CDM,0942,RC,G0271,HCPCS,,,,,,outpatient,facility,,,56.00,16.80,12.99,312.0,,34.61,,,percent of total billed charges,,,13.01,,,fee schedule,,,27.33,,,percent of total billed charges,,,28.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.49,,,fee schedule,,,,,,,,service not payable,13.25,,,fee schedule,,,29.97,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,,,,,,,23.80,,,percent of total billed charges,,,27.09,,,fee schedule,,,42.0,,,percent of total billed charges,,,13.01,,,fee schedule,,,,,,,,service not payable,13.27,,,fee schedule,,,28.0,,,percent of total billed charges,,,12.99,,,fee schedule,,,42.0,,,percent of total billed charges,,,,,,,,service not payable,13.27,,,fee schedule,,,,,,,,,47.60,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,,,,,,,312.0,,,per diem,,,12.99,,,fee schedule,,,,,,,,,275.0,,,per diem,,,13.01,,,fee schedule,,,,,,,,,13.01,,,fee schedule,,,,,,,,
DM-Medical Nutrition Therapy Group Each 30 Minut,10506409,CDM,0942,RC,G0271,HCPCS,118,EAPG,,,,outpatient,facility,,,56.00,16.80,56.0,404.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,344.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,56.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,56.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,120.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH IC 3-WAY 30ML 24F X_0167SI24 X_105040,10506534,CDM,0272,RC,A4346,HCPCS,,,,,,outpatient,facility,,,94.00,28.20,39.95,79.90,,58.09,,,percent of total billed charges,,,,,,,,service not payable,45.87,,,percent of total billed charges,,,47.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,39.95,,,percent of total billed charges,,,,,,,,,70.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,47.0,,,percent of total billed charges,,,,,,,,service not payable,70.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,79.90,,,percent of total billed charges,,,43.24,,,percent of total billed charges,,,,,,,,,61.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,61.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
No - Differential Indicated,10507766,CDM,0300,RC,89050,CPT,,,,,,outpatient,facility,,,60.00,18.00,4.48,51.0,,15.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.63,,,fee schedule,,,11.49,,,fee schedule,,,9.85,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,9.77,,,fee schedule,,,4.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.72,,,fee schedule,,,10.67,,,fee schedule,,,,,,,,,4.63,,,fee schedule,,,,,,,,,5.89,,,fee schedule,,,9.63,,,fee schedule,,,45.0,,,percent of total billed charges,,,4.63,,,fee schedule,,,4.48,,,fee schedule,,,4.72,,,fee schedule,,,6.93,,,fee schedule,,,4.63,,,fee schedule,,,45.0,,,percent of total billed charges,,,,,,,,,4.72,,,fee schedule,,,,,,,,,51.0,,,percent of total billed charges,,,27.60,,,percent of total billed charges,,,,,,,,,5.19,,,fee schedule,,,4.63,,,fee schedule,,,,,,,,,4.58,,,fee schedule,,,4.63,,,fee schedule,,,,,,,,,4.67,,,fee schedule,,,,,,,,
No - Differential Indicated,10507766,CDM,0300,RC,89050,CPT,390,EAPG,,,,outpatient,facility,,,60.00,18.00,5.88,120.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,102.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.44,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Yes - Differential Indicated,10507767,CDM,0300,RC,89051,CPT,,,,,,outpatient,facility,,,67.00,20.10,5.32,56.95,,23.39,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.49,,,fee schedule,,,17.45,,,fee schedule,,,11.68,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.59,,,fee schedule,,,5.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.60,,,fee schedule,,,12.66,,,fee schedule,,,,,,,,,5.49,,,fee schedule,,,,,,,,,7.16,,,fee schedule,,,11.42,,,fee schedule,,,50.25,,,percent of total billed charges,,,5.49,,,fee schedule,,,5.32,,,fee schedule,,,5.60,,,fee schedule,,,8.41,,,fee schedule,,,5.49,,,fee schedule,,,50.25,,,percent of total billed charges,,,,,,,,,5.60,,,fee schedule,,,,,,,,,56.95,,,percent of total billed charges,,,30.82,,,percent of total billed charges,,,,,,,,,6.16,,,fee schedule,,,5.49,,,fee schedule,,,,,,,,,5.43,,,fee schedule,,,5.49,,,fee schedule,,,,,,,,,5.55,,,fee schedule,,,,,,,,
Yes - Differential Indicated,10507767,CDM,0300,RC,89051,CPT,390,EAPG,,,,outpatient,facility,,,67.00,20.10,5.88,120.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,102.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5.88,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.44,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT AXIOS 15X15MM,10508027,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,16375.00,4912.50,6353.5,13918.75,,8023.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6877.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6353.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6959.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12281.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8187.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13918.75,,,percent of total billed charges,,,7368.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT AXIOS 15X15MM,10508027,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,16375.00,4912.50,6877.5,13918.75,,8023.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6877.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8259.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6959.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12281.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8187.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12281.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13918.75,,,percent of total billed charges,,,7532.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE LOOP CERCLAGE LUQUE SS,10508028,CDM,0272,RC,C1889,HCPCS,,,,,,outpatient,facility,,,404.00,121.20,171.70,343.40,,249.67,,,percent of total billed charges,,,,,,,,service not payable,197.15,,,percent of total billed charges,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.70,,,percent of total billed charges,,,,,,,,,303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,202.0,,,percent of total billed charges,,,,,,,,service not payable,303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,262.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,262.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DRAIN WOUND J-P PVC 3/16IN 7MM,10508029,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,63.00,18.90,26.77,53.55,,38.93,,,percent of total billed charges,,,,,,,,service not payable,30.74,,,percent of total billed charges,,,31.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,26.77,,,percent of total billed charges,,,,,,,,,47.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,31.5,,,percent of total billed charges,,,,,,,,service not payable,47.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,53.55,,,percent of total billed charges,,,28.98,,,percent of total billed charges,,,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,40.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VARIAX STRT 7H STERILE,10508030,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2078.00,623.40,806.26,1766.3,,,,,,,,,,,,,,,,,,,,806.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,883.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1558.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1766.3,,,percent of total billed charges,,,935.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VARIAX STRT 7H STERILE,10508030,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2078.00,623.40,883.15,1766.3,,,,,,,,,,,,,service not payable,,,,,,,1048.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,883.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1558.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1039.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1558.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1766.3,,,percent of total billed charges,,,955.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 5X30,10508031,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 5X30,10508031,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 4.5X30MM,10508032,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 4.5X30MM,10508032,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 4X28MM,10508033,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 4X28MM,10508033,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONTOURED 3.5 X 75MM,10508034,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONTOURED 3.5 X 75MM,10508034,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR TRANSVERSE ADJ S,10508035,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR TRANSVERSE ADJ S,10508035,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING 8F 45D,10508036,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING 8F 55D,10508037,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING 8F 90D,10508038,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING 8.5F 90D,10508039,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING 8.5F 45D,10508040,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING 8.5F 55D,10508041,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VASC PIGTAIL 0.025IN,10508042,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,558.05,,,percent of total billed charges,,,,,,,,service not payable,440.66,,,percent of total billed charges,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,586.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ANG LKING 2.4X22MM,10508526,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ANG LKING 2.4X22MM,10508526,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 135D 12X140MM,10508527,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 135D 12X140MM,10508527,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB G7 LH SZ G 60MM,10508528,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB G7 LH SZ G 60MM,10508528,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR HW G7 40MM,10508529,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR HW G7 40MM,10508529,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST RAD TI NRW LT 3H,10508531,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST RAD TI NRW LT 3H,10508531,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 3.5X12MM,10508532,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 3.5X12MM,10508532,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS EXCLSN ATRICLIP 45MM FLEX,10508533,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN ATRICLIP 45MM FLEX,10508533,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN SH 130D 170X12MM,10508534,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7639.00,2291.70,2963.93,6493.15,,3743.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3208.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2963.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3246.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5729.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6493.15,,,percent of total billed charges,,,3437.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN SH 130D 170X12MM,10508534,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7639.00,2291.70,3208.38,6493.15,,3743.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3208.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3853.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3246.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5729.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5729.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6493.15,,,percent of total billed charges,,,3513.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLADE NAIL FEM TI 10.5X95MM,10508535,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3486.00,1045.80,1352.57,2963.10,,,,,,,,,,,,,,,,,,,,1352.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1481.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2614.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1743.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2963.10,,,percent of total billed charges,,,1568.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLADE NAIL FEM TI 10.5X95MM,10508535,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3486.00,1045.80,1481.55,2963.10,,,,,,,,,,,,,service not payable,,,,,,,1758.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1481.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2614.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1743.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2614.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2963.10,,,percent of total billed charges,,,1603.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 4X80MMX130CM,10508536,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 8X57MM 135CM,10508537,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 8X57MM 135CM,10508537,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER CLOSURE X_CF7-3-60 X_MEDTRONIC USA INC,10508538,CDM,0272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,3256.00,976.80,1383.8,2767.60,,2012.21,,,percent of total billed charges,,,,,,,,service not payable,1588.93,,,percent of total billed charges,,,1642.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1383.8,,,percent of total billed charges,,,,,,,,,2442.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1628.0,,,percent of total billed charges,,,,,,,,service not payable,2442.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2767.60,,,percent of total billed charges,,,1497.76,,,percent of total billed charges,,,,,,,,,2116.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2116.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Bundle of His Recording,10509163,CDM,0481,RC,93600,CPT,,,,,,outpatient,facility,,,18391.00,5517.30,1972.0,15632.35,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,9276.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,13793.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,13793.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15632.35,,,percent of total billed charges,,,8459.86,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Bundle of His Recording,10509163,CDM,0481,RC,93600,CPT,05212,APC,,,,outpatient,facility,,,18391.00,5517.30,6979.74,16712.84,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,15307.77,,,fee schedule,,,6979.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7422.27,,,fee schedule,,,16712.84,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,15085.92,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,6979.74,,,fee schedule,,,7422.27,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,6979.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",7422.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,7349.21,,,fee schedule,,,,,,,,
Bundle of His Recording,10509163,CDM,0481,RC,93600,CPT,96,EAPG,,,,outpatient,facility,,,18391.00,5517.30,9268.92,18075.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18075.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,15364.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9268.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,9268.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,9268.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14048.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,15453.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANN 7X80MM,10509265,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1124.00,337.20,436.11,955.40,,,,,,,,,,,,,,,,,,,,436.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,955.40,,,percent of total billed charges,,,505.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 7X80MM,10509265,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1124.00,337.20,477.70,955.40,,,,,,,,,,,,,service not payable,,,,,,,566.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,477.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,843.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,562.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,843.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,955.40,,,percent of total billed charges,,,517.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT DRP LP 3.5X12MM,10509268,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT DRP LP 3.5X12MM,10509268,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT DRP LP 3.5X10MM,10509269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT DRP LP 3.5X10MM,10509269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT DRP LP 3.5X14MM,10509270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT DRP LP 3.5X14MM,10509270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST RAD LP 3H STD LT,10509271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST RAD LP 3H STD LT,10509271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TAPER DIST 17X250MM,10509272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12053.00,3615.90,4676.56,10245.05,,5905.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5062.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4676.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5122.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9039.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6026.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10245.05,,,percent of total billed charges,,,5423.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TAPER DIST 17X250MM,10509272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12053.00,3615.90,5062.26,10245.05,,5905.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5062.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6079.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5122.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9039.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6026.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9039.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10245.05,,,percent of total billed charges,,,5544.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TAPER DIST 18X250MM,10509273,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13195.00,3958.50,5119.66,11215.75,,6465.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5541.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5119.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9896.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6597.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11215.75,,,percent of total billed charges,,,5937.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TAPER DIST 18X250MM,10509273,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13195.00,3958.50,5541.90,11215.75,,6465.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5541.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6655.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5607.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9896.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6597.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9896.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11215.75,,,percent of total billed charges,,,6069.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB G7 SZ F 44MM,10509274,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5665.00,1699.50,2198.02,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2198.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4815.25,,,percent of total billed charges,,,2549.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB G7 SZ F 44MM,10509274,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5665.00,1699.50,2379.30,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2857.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4815.25,,,percent of total billed charges,,,2605.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM MED 28MM MINUS 3MM,10509276,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM MED 28MM MINUS 3MM,10509276,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE HIP ACROS STD SZB 70MM,10509277,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21112.00,6333.60,8191.46,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8191.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17945.20,,,percent of total billed charges,,,9500.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE HIP ACROS STD SZB 70MM,10509277,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21112.00,6333.60,8867.04,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10648.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17945.20,,,percent of total billed charges,,,9711.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON IN.PACT ADML 5X200X130,10509287,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,6705.00,2011.50,2849.63,5699.25,,4143.69,,,percent of total billed charges,,,,,,,,service not payable,3272.04,,,percent of total billed charges,,,3382.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2849.63,,,percent of total billed charges,,,,,,,,,5028.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3352.5,,,percent of total billed charges,,,,,,,,service not payable,5028.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5699.25,,,percent of total billed charges,,,3084.30,,,percent of total billed charges,,,,,,,,,4358.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4358.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON IN.PACT ADML 5X250X130,10509288,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3135.22,6270.45,,4558.99,,,percent of total billed charges,,,,,,,,service not payable,3599.98,,,percent of total billed charges,,,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,4795.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4795.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP VA TI 2.4X20MM,10509601,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP VA TI 2.4X20MM,10509601,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK TI 3.5X12MM,10509602,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK TI 3.5X12MM,10509602,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ENDO II HIP 44MM,10509606,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ENDO II HIP 44MM,10509606,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM STD OFFSET 60MM SZ B,10509607,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21112.00,6333.60,8191.46,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8191.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17945.20,,,percent of total billed charges,,,9500.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM STD OFFSET 60MM SZ B,10509607,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21112.00,6333.60,8867.04,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10648.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17945.20,,,percent of total billed charges,,,9711.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TYPE 1 MINUS 6.0MM,10509609,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TYPE 1 MINUS 6.0MM,10509609,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDCAP TIBIAL EXT NAIL-EX 10MM,10509728,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1784.00,535.20,692.19,1516.40,,,,,,,,,,,,,,,,,,,,692.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1516.40,,,percent of total billed charges,,,802.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDCAP TIBIAL EXT NAIL-EX 10MM,10509728,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1784.00,535.20,758.20,1516.40,,,,,,,,,,,,,service not payable,,,,,,,899.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1516.40,,,percent of total billed charges,,,820.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 27.0,10509729,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 27.0,10509729,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75D 24.0,10509730,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75D 24.0,10509730,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR TRANSV MINI ADJ S,10509731,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR TRANSV MINI ADJ S,10509731,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR 46MM,10509808,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4344.00,1303.20,1685.47,3692.40,,,,,,,,,,,,,,,,,,,,1685.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1846.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3258.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2172.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3692.40,,,percent of total billed charges,,,1954.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR 46MM,10509808,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4344.00,1303.20,1846.2,3692.40,,,,,,,,,,,,,service not payable,,,,,,,2191.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1846.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3258.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2172.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3258.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3692.40,,,percent of total billed charges,,,1998.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL SMALL 46,10509809,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL SMALL 46,10509809,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL SMALL,10509810,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL SMALL,10509810,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX34CM 125D R,10509811,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4462.00,1338.60,1731.26,3792.70,,,,,,,,,,,,,,,,,,,,1731.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1896.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3346.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2231.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3792.70,,,percent of total billed charges,,,2007.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX34CM 125D R,10509811,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4462.00,1338.60,1896.35,3792.70,,,,,,,,,,,,,service not payable,,,,,,,2250.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1896.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3346.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2231.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3346.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3792.70,,,percent of total billed charges,,,2052.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE FOOT TI LP 2 HOLE,10509813,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE FOOT TI LP 2 HOLE,10509813,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Reconstruct polydactylous digit soft tissue and b,10509838,CDM,0450,RC,26587,CPT,,,,,,outpatient,facility,,,7129.00,2138.70,774.0,6059.65,,4405.72,,,percent of total billed charges,,,,,,,,,3478.95,,,percent of total billed charges,,,3595.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5346.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5346.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6059.65,,,percent of total billed charges,,,3279.34,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Reconstruct polydactylous digit soft tissue and b,10509838,CDM,0450,RC,26587,CPT,05113,APC,,,,outpatient,facility,,,7129.00,2138.70,1492.24,7146.28,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6545.48,,,fee schedule,,,1492.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3173.71,,,fee schedule,,,7146.28,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6450.62,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,1492.24,,,fee schedule,,,3173.71,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,1492.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3173.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,3142.46,,,fee schedule,,,,,,,,
Reconstruct polydactylous digit soft tissue and b,10509838,CDM,0450,RC,26587,CPT,34,EAPG,,,,outpatient,facility,,,7129.00,2138.70,3130.06,6334.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6334.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5384.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3130.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3130.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3130.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4941.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5435.54,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHELL ACETAB HIP G7 SZ C 48MM,10510121,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ C 48MM,10510121,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR HW G7 32MM,10510122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR HW G7 32MM,10510122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 16X150MM,10510123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10885.00,3265.50,4223.38,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4223.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9252.25,,,percent of total billed charges,,,4898.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 16X150MM,10510123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10885.00,3265.50,4571.70,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5490.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9252.25,,,percent of total billed charges,,,5007.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TYPE 1 TAPER 32MM,10510124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7311.00,2193.30,2836.67,6214.35,,3582.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3070.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2836.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3107.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6214.35,,,percent of total billed charges,,,3289.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TYPE 1 TAPER 32MM,10510124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7311.00,2193.30,3070.62,6214.35,,3582.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3070.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3687.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3107.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6214.35,,,percent of total billed charges,,,3363.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TYPE 1 TAPER -3.0MM,10510125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TYPE 1 TAPER -3.0MM,10510125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER EVERA MRI XT DR,10510126,CDM,0278,RC,C1721,HCPCS,,,,,,inpatient,facility,,,22272.00,6681.60,8641.54,18931.20,,10913.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9354.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8641.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9465.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16704.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18931.20,,,percent of total billed charges,,,10022.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER EVERA MRI XT DR,10510126,CDM,0278,RC,C1721,HCPCS,,,,,,outpatient,facility,,,22272.00,6681.60,9354.24,18931.20,,10913.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9354.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11234.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9465.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16704.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16704.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18931.20,,,percent of total billed charges,,,10245.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB LCP 6H LT 3.5X117MM,10510235,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7290.00,2187.00,2828.52,6196.5,,3572.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3061.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2828.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5467.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3645.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6196.5,,,percent of total billed charges,,,3280.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB LCP 6H LT 3.5X117MM,10510235,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7290.00,2187.00,3061.80,6196.5,,3572.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3061.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3677.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3098.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5467.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3645.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5467.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6196.5,,,percent of total billed charges,,,3353.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LKING T15 3.5X34MM,10510236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LKING T15 3.5X34MM,10510236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LKING T15 3.5X75MM,10510237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LKING T15 3.5X75MM,10510237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LKING T15 3.5X80MM,10510238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LKING T15 3.5X80MM,10510238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 1.6X200MM,10510239,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,302.00,90.60,128.35,256.70,,186.64,,,percent of total billed charges,,,,,,,,service not payable,147.38,,,percent of total billed charges,,,152.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,128.35,,,percent of total billed charges,,,,,,,,,226.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,151.0,,,percent of total billed charges,,,,,,,,service not payable,226.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,256.70,,,percent of total billed charges,,,138.92,,,percent of total billed charges,,,,,,,,,196.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,196.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK T8 FT 2.4 X 26MM,10510241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK T8 FT 2.4 X 26MM,10510241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Programmed Stimulation after IV drug infusion,10510298,CDM,0481,RC,93623,CPT,,,,,,outpatient,facility,,,3570.00,1071.00,1106.0,5463.36,,3570.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,1800.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,2677.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,2677.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3034.5,,,percent of total billed charges,,,1642.2,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Programmed Stimulation after IV drug infusion,10510298,CDM,0481,RC,93623,CPT,96,EAPG,,,,outpatient,facility,,,3570.00,1071.00,3570.0,18075.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18075.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,15364.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3570.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3570.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3570.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14048.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,15453.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE LCP 8H 2.7X76MM,10510306,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2601.00,780.30,1009.19,2210.85,,,,,,,,,,,,,,,,,,,,1009.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2210.85,,,percent of total billed charges,,,1170.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 8H 2.7X76MM,10510306,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,,,,,,,,,,,,service not payable,,,,,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXTENSION PERCUTANEOUS,10510520,CDM,0278,RC,C1883,HCPCS,,,,,,inpatient,facility,,,3755.00,1126.50,1456.94,3191.75,,,,,,,,,,,,,,,,,,,,1456.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1595.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2816.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1877.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3191.75,,,percent of total billed charges,,,1689.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXTENSION PERCUTANEOUS,10510520,CDM,0278,RC,C1883,HCPCS,,,,,,outpatient,facility,,,3755.00,1126.50,1595.88,3191.75,,,,,,,,,,,,,service not payable,,,,,,,1894.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1595.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2816.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1877.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2816.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3191.75,,,percent of total billed charges,,,1727.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 5X44MM,10510521,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5796.00,1738.80,2248.85,4926.60,,2840.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2434.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2248.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2463.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4347.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2898.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4926.60,,,percent of total billed charges,,,2608.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 5X44MM,10510521,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5796.00,1738.80,2434.32,4926.60,,2840.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2434.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2923.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2463.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4347.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2898.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4347.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4926.60,,,percent of total billed charges,,,2666.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH THROMBECTOMY 90CM,10510522,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,5508.00,1652.40,2340.90,4681.80,,3403.94,,,percent of total billed charges,,,,,,,,service not payable,2687.90,,,percent of total billed charges,,,2778.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2340.90,,,percent of total billed charges,,,,,,,,,4131.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.0,,,percent of total billed charges,,,,,,,,service not payable,4131.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4681.80,,,percent of total billed charges,,,2533.68,,,percent of total billed charges,,,,,,,,,3580.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3580.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIB COMP SZ4 31X44X5MM,10510523,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18361.00,5508.30,7124.07,15606.85,,8996.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7711.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7124.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13770.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15606.85,,,percent of total billed charges,,,8262.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIB COMP SZ4 31X44X5MM,10510523,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18361.00,5508.30,7711.62,15606.85,,8996.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7711.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9261.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7803.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13770.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13770.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15606.85,,,percent of total billed charges,,,8446.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ANKLE INFIN POLY SZ3 7M,10510524,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ANKLE INFIN POLY SZ3 7M,10510524,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRO DRYSEAL 26FRX33CM,10510526,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH FENESTRATED,10510527,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1108.00,332.40,429.90,941.80,,,,,,,,,,,,,,,,,,,,429.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,831.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,554.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,941.80,,,percent of total billed charges,,,498.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH FENESTRATED,10510527,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1108.00,332.40,470.90,941.80,,,,,,,,,,,,,service not payable,,,,,,,558.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,470.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,831.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,554.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,831.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,941.80,,,percent of total billed charges,,,509.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIXATION KIT TOGGLELOC NO 7,10510528,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1882.00,564.60,730.22,1599.7,,,,,,,,,,,,,,,,,,,,730.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1411.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,941.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1599.7,,,percent of total billed charges,,,846.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIXATION KIT TOGGLELOC NO 7,10510528,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1882.00,564.60,799.85,1599.7,,,,,,,,,,,,,service not payable,,,,,,,949.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,799.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1411.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,941.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1411.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1599.7,,,percent of total billed charges,,,865.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Inject diag/therapeutic substance w/needle or cath,10510742,CDM,0761,RC,62323,CPT,,,,,,outpatient,facility,,,2138.00,641.40,118.0,1817.3,,1321.28,,,percent of total billed charges,,,,,,,,,1043.34,,,percent of total billed charges,,,1078.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.65,,,percent of total billed charges,,,,,,,,,1603.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1069.0,,,percent of total billed charges,,,,,,,,,1603.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1817.3,,,percent of total billed charges,,,983.48,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Inject diag/therapeutic substance w/needle or cath,10510742,CDM,0761,RC,62323,CPT,05442,APC,,,,outpatient,facility,,,2138.00,641.40,637.0,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,637.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.8,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,637.0,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,637.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Inject diag/therapeutic substance w/needle or cath,10510742,CDM,0761,RC,62323,CPT,53,EAPG,,,,outpatient,facility,,,2138.00,641.40,1111.36,2217.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2217.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1885.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1111.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1163.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1280.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Irrigation of Corcpora Cavernosa for Priapism,10510744,CDM,0490,RC,54220,CPT,,,,,,outpatient,facility,,,713.00,213.90,327.98,2912.34,,713.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,359.64,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,534.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,534.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,606.05,,,percent of total billed charges,,,327.98,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Irrigation of Corcpora Cavernosa for Priapism,10510744,CDM,0490,RC,54220,CPT,05371,APC,,,,outpatient,facility,,,713.00,213.90,223.71,535.67,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,490.63,,,fee schedule,,,223.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",237.89,,,fee schedule,,,535.67,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,483.52,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,223.71,,,fee schedule,,,237.89,,,fee schedule,,,,,,,,,233.23,,,fee schedule,,,,,,,,,223.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",237.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,235.55,,,fee schedule,,,,,,,,
Irrigation of Corcpora Cavernosa for Priapism,10510744,CDM,0490,RC,54220,CPT,159,EAPG,,,,outpatient,facility,,,713.00,213.90,125.32,525.80,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.80,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,446.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,125.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,125.32,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,223.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,245.52,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Tracheobronch thru established tracheostomy,10510775,CDM,0450,RC,31615,CPT,,,,,,outpatient,facility,,,1152.00,345.60,529.92,979.20,,711.94,,,percent of total billed charges,,,,,,,,,562.18,,,percent of total billed charges,,,581.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,864.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,864.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,979.20,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tracheobronch thru established tracheostomy,10510775,CDM,0450,RC,31615,CPT,05162,APC,,,,outpatient,facility,,,1152.00,345.60,234.21,1121.62,,,,,,,,488.35,,,fee schedule,,,,,,,,,,,,,,,1027.32,,,fee schedule,,,234.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",498.12,,,fee schedule,,,1121.62,,,fee schedule,,,,,,,,,488.35,,,fee schedule,,,,,,,,,,,,,,,1012.43,,,fee schedule,,,,,,,,,488.35,,,fee schedule,,,234.21,,,fee schedule,,,498.12,,,fee schedule,,,,,,,,,488.35,,,fee schedule,,,,,,,,,234.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",498.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.35,,,fee schedule,,,,,,,,,,,,,,,488.35,,,fee schedule,,,,,,,,,493.21,,,fee schedule,,,,,,,,
Tracheobronch thru established tracheostomy,10510775,CDM,0450,RC,31615,CPT,64,EAPG,,,,outpatient,facility,,,1152.00,345.60,1152.0,6789.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6789.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5771.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1152.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1152.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1152.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1824.04,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2006.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM FEMORAL GV MOD LG,10510784,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL GV MOD LG,10510784,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON LOCK T8 FT 2.7X10MM,10510785,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,720.00,216.00,279.36,612.0,,,,,,,,,,,,,,,,,,,,279.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.0,,,percent of total billed charges,,,324.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LOCK T8 FT 2.7X10MM,10510785,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,720.00,216.00,306.0,612.0,,,,,,,,,,,,,service not payable,,,,,,,363.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.0,,,percent of total billed charges,,,331.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER STEM EXTENSION 175,10510786,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER STEM EXTENSION 175,10510786,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER FEM COMP STEMMED XL,10510787,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER FEM COMP STEMMED XL,10510787,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER TIB COMP STEMMED LG,10510788,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER TIB COMP STEMMED LG,10510788,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER STEM EXTENSION 100,10510789,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER STEM EXTENSION 100,10510789,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE ANCHOR F-STITCH 2-0 CRV,10510790,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE ANCHOR F-STITCH 2-0 CRV,10510790,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEMUR DISTAL LAT LT 16H,10510791,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10221.00,3066.30,3965.75,8687.85,,5008.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4292.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3965.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4343.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7665.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5110.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8687.85,,,percent of total billed charges,,,4599.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEMUR DISTAL LAT LT 16H,10510791,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10221.00,3066.30,4292.82,8687.85,,5008.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4292.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5155.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4343.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7665.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5110.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7665.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8687.85,,,percent of total billed charges,,,4701.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK AXSOS TI 5.0X16MM,10510792,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1301.00,390.30,504.79,1105.85,,,,,,,,,,,,,,,,,,,,504.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.85,,,percent of total billed charges,,,585.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK AXSOS TI 5.0X16MM,10510792,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1301.00,390.30,552.92,1105.85,,,,,,,,,,,,,service not payable,,,,,,,656.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.85,,,percent of total billed charges,,,598.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LID PROFYLE MODULE PLATES,10510793,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,621.00,186.30,240.95,527.85,,,,,,,,,,,,,,,,,,,,240.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,465.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,310.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.85,,,percent of total billed charges,,,279.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LID PROFYLE MODULE PLATES,10510793,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,621.00,186.30,263.93,527.85,,,,,,,,,,,,,service not payable,,,,,,,313.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,263.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,465.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,310.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,465.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,527.85,,,percent of total billed charges,,,285.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LID PROFYLE MODULE SCREW,10510794,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,621.00,186.30,240.95,527.85,,,,,,,,,,,,,,,,,,,,240.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,465.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,310.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.85,,,percent of total billed charges,,,279.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LID PROFYLE MODULE SCREW,10510794,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,621.00,186.30,263.93,527.85,,,,,,,,,,,,,service not payable,,,,,,,313.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,263.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,465.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,310.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,465.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,527.85,,,percent of total billed charges,,,285.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GENERATOR MRI SAFE IPG NOVI,10510795,CDM,0278,RC,C1767,HCPCS,,,,,,inpatient,facility,,,30706.00,9211.80,11913.93,26100.10,,15045.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12896.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11913.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13050.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23029.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15353.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26100.10,,,percent of total billed charges,,,13817.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENERATOR MRI SAFE IPG NOVI,10510795,CDM,0278,RC,C1767,HCPCS,,,,,,outpatient,facility,,,30706.00,9211.80,12896.52,26100.10,,15045.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12896.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15488.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13050.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23029.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15353.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23029.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26100.10,,,percent of total billed charges,,,14124.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X10MM,10510797,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X10MM,10510797,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CORE MONI XC 14X12-24MM,10510798,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,15549.00,4664.70,6033.01,13216.65,,7619.01,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6530.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6033.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6608.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11661.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7774.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13216.65,,,percent of total billed charges,,,6997.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CORE MONI XC 14X12-24MM,10510798,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,15549.00,4664.70,6530.58,13216.65,,7619.01,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6530.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7842.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6608.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11661.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7774.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11661.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13216.65,,,percent of total billed charges,,,7152.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDCAP MINI XC 17X14MM TOP,10510799,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3856.00,1156.80,1496.13,3277.60,,,,,,,,,,,,,,,,,,,,1496.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.60,,,percent of total billed charges,,,1735.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDCAP MINI XC 17X14MM TOP,10510799,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3856.00,1156.80,1638.8,3277.60,,,,,,,,,,,,,service not payable,,,,,,,1944.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3277.60,,,percent of total billed charges,,,1773.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ENDCAP MINI XC 17X14MM BTM,10510800,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3856.00,1156.80,1496.13,3277.60,,,,,,,,,,,,,,,,,,,,1496.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.60,,,percent of total billed charges,,,1735.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENDCAP MINI XC 17X14MM BTM,10510800,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3856.00,1156.80,1638.8,3277.60,,,,,,,,,,,,,service not payable,,,,,,,1944.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3277.60,,,percent of total billed charges,,,1773.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MINI XC ENDCAP,10510801,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1743.00,522.90,676.28,1481.55,,,,,,,,,,,,,,,,,,,,676.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,740.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1307.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,871.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1481.55,,,percent of total billed charges,,,784.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MINI XC ENDCAP,10510801,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1743.00,522.90,740.77,1481.55,,,,,,,,,,,,,service not payable,,,,,,,879.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,740.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1307.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,871.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1307.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1481.55,,,percent of total billed charges,,,801.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT DISTAL TIBIA 3H 74MM,10510802,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3598.00,1079.40,1396.02,3058.30,,,,,,,,,,,,,,,,,,,,1396.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1529.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2698.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1799.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3058.30,,,percent of total billed charges,,,1619.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT DISTAL TIBIA 3H 74MM,10510802,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3598.00,1079.40,1529.15,3058.30,,,,,,,,,,,,,service not payable,,,,,,,1814.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1529.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2698.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1799.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2698.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3058.30,,,percent of total billed charges,,,1655.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5MM X 22MM,10510803,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5MM X 22MM,10510803,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5MM X 42MM,10510804,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5MM X 42MM,10510804,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COVID-19 Antibody IgG (3002776),10510914,CDM,0300,RC,86769,CPT,,,,,,outpatient,facility,,,85.00,25.50,39.10,95.21,,42.13,,,fee schedule,,Paid in addition to outpatient services ,41.29,,,fee schedule,,,42.13,,,fee schedule,,Paid in addition to outpatient services ,87.86,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,87.21,,,fee schedule,,,40.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",42.12,,,fee schedule,,,95.21,,,fee schedule,,,,,,,,,41.29,,,fee schedule,,,,,,,,,54.34,,,fee schedule,,,85.95,,,fee schedule,,,63.75,,,percent of total billed charges,,,41.29,,,fee schedule,,,40.02,,,fee schedule,,,42.12,,,fee schedule,,,63.90,,,fee schedule,,,41.29,,,fee schedule,,,63.75,,,percent of total billed charges,,,40.02,,,fee schedule,,,42.12,,,fee schedule,,,,,,,,,72.25,,,percent of total billed charges,,,39.10,,,percent of total billed charges,,,,,,,,,46.34,,,fee schedule,,,41.29,,,fee schedule,,,,,,,,,40.87,,,fee schedule,,,41.29,,,fee schedule,,,,,,,,,41.70,,,fee schedule,,,,,,,,
COVID-19 Antibody IgG (3002776),10510914,CDM,0300,RC,86769,CPT,394,EAPG,,,,outpatient,facility,,,85.00,25.50,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Q3014 WC-Telehealth originating site facility fee,10511163,CDM,0510,RC,Q3014,HCPCS,,,,,,outpatient,facility,,,87.00,26.10,20.74,73.95,,53.77,,,percent of total billed charges,,,30.51,,,fee schedule,,,42.46,,,percent of total billed charges,,,43.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,64.19,,,fee schedule,,,20.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",31.12,,,fee schedule,,,70.08,,,fee schedule,,,,,,,,,30.51,,,fee schedule,,,,,,,,,,,,,,service not payable,63.26,,,fee schedule,,,65.25,,,percent of total billed charges,,,30.51,,,fee schedule,,,20.74,,,fee schedule,,,31.12,,,fee schedule,,,,,,,,service not payable,30.51,,,fee schedule,,,,,,,,service not payable,20.74,,,fee schedule,,,31.12,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,30.51,,,fee schedule,,,,,,,,,56.55,,,percent of total billed charges,,,30.51,,,fee schedule,,,,,,,,,30.82,,,fee schedule,,,,,,,,
Q3014 WC-Telehealth originating site facility fee,10511163,CDM,0510,RC,Q3014,HCPCS,497,EAPG,,,,outpatient,facility,,,87.00,26.10,40.39,65.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,40.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,65.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM HIP ECHO 135D 15X155MM,10511197,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 135D 15X155MM,10511197,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TFNA FENESTRATED 80MM,10511198,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TFNA FENESTRATED 80MM,10511198,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFNA 11MMX340MM L 130 DEG,10511199,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFNA 11MMX340MM L 130 DEG,10511199,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN FT 4X30MM,10511200,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN FT 4X30MM,10511200,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Replace/Remove implantable card/defibrillator gene,10511264,CDM,0481,RC,33262,CPT,,,,,,outpatient,facility,,,52178.00,15653.40,4917.20,50947.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,26318.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,39133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50947.0,,,case rate,,,,,,,,,39133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44351.30,,,percent of total billed charges,,,24001.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Replace/Remove implantable card/defibrillator gene,10511264,CDM,0481,RC,33262,CPT,05231,APC,,,,outpatient,facility,,,52178.00,15653.40,20646.60,49437.86,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,45281.58,,,fee schedule,,,20646.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21900.60,,,fee schedule,,,49437.86,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,44625.33,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,20646.60,,,fee schedule,,,21900.60,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,20646.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",21900.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,21685.55,,,fee schedule,,,,,,,,
Replace/Remove implantable card/defibrillator gene,10511264,CDM,0481,RC,33262,CPT,97,EAPG,,,,outpatient,facility,,,52178.00,15653.40,32245.61,50588.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50588.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,42999.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42921.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,47214.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Insert pacemaker pulse generator w/existing multip,10511286,CDM,0481,RC,33221,CPT,,,,,,outpatient,facility,,,27319.00,8195.70,4917.20,23221.15,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,13779.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,20489.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,20489.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23221.15,,,percent of total billed charges,,,12566.74,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert pacemaker pulse generator w/existing multip,10511286,CDM,0481,RC,33221,CPT,05224,APC,,,,outpatient,facility,,,27319.00,8195.70,17542.16,42004.34,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,38473.00,,,fee schedule,,,17542.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18612.75,,,fee schedule,,,42004.34,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,37915.42,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,17542.16,,,fee schedule,,,18612.75,,,fee schedule,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,17542.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",18612.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,,,,,,,18247.79,,,fee schedule,,,,,,,,,18429.93,,,fee schedule,,,,,,,,
Insert pacemaker pulse generator w/existing multip,10511286,CDM,0481,RC,33221,CPT,86,EAPG,,,,outpatient,facility,,,27319.00,8195.70,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SYS EXCLSN ATRICLIP 50MM FLEX,10511301,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS EXCLSN ATRICLIP 50MM FLEX,10511301,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW DVR CROSSLOCK 20X2.7MM,10512555,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,793.00,237.90,307.68,674.05,,,,,,,,,,,,,,,,,,,,307.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,356.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW DVR CROSSLOCK 20X2.7MM,10512555,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,,,,,,,,,,,,service not payable,,,,,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NAT 125D 13MMX38CM,10512556,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NAT 125D 13MMX38CM,10512556,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LKING 6H FIB RT 106MM,10512558,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2886.00,865.80,1119.77,2453.10,,,,,,,,,,,,,,,,,,,,1119.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1226.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2164.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1443.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2453.10,,,percent of total billed charges,,,1298.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LKING 6H FIB RT 106MM,10512558,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2886.00,865.80,1226.55,2453.10,,,,,,,,,,,,,service not payable,,,,,,,1455.7,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1226.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2164.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1443.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2164.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2453.10,,,percent of total billed charges,,,1327.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X80MM,10512559,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X80MM,10512559,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X38MM,10512560,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X38MM,10512560,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X30MM,10512561,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X30MM,10512561,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X32MM,10512562,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X32MM,10512562,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X12MM,10512563,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,571.00,171.30,221.55,485.35,,,,,,,,,,,,,,,,,,,,221.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,428.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,285.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.35,,,percent of total billed charges,,,256.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X12MM,10512563,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,571.00,171.30,242.67,485.35,,,,,,,,,,,,,service not payable,,,,,,,288.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,242.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,428.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,285.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,428.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,485.35,,,percent of total billed charges,,,262.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDE T-W HALO 10CM 5FR,10512564,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,337.43,,,percent of total billed charges,,,,,,,,service not payable,266.45,,,percent of total billed charges,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 4X40MMX40CM,10512565,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,5377.00,1613.10,2285.22,4570.45,,3322.99,,,percent of total billed charges,,,,,,,,service not payable,2623.98,,,percent of total billed charges,,,2712.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2285.22,,,percent of total billed charges,,,,,,,,,4032.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2688.5,,,percent of total billed charges,,,,,,,,service not payable,4032.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4570.45,,,percent of total billed charges,,,2473.42,,,percent of total billed charges,,,,,,,,,3495.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3495.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIXATION SYSTEM ZIPTIGHT,10512566,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4319.00,1295.70,1675.77,3671.15,,,,,,,,,,,,,,,,,,,,1675.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1835.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3239.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2159.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3671.15,,,percent of total billed charges,,,1943.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIXATION SYSTEM ZIPTIGHT,10512566,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4319.00,1295.70,1835.58,3671.15,,,,,,,,,,,,,service not payable,,,,,,,2178.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1835.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3239.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2159.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3239.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3671.15,,,percent of total billed charges,,,1986.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT JUGGERKNOT TN 2.9MM,10512567,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1300.00,390.00,504.40,1105.0,,,,,,,,,,,,,,,,,,,,504.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.0,,,percent of total billed charges,,,585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT JUGGERKNOT TN 2.9MM,10512567,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1300.00,390.00,552.5,1105.0,,,,,,,,,,,,,service not payable,,,,,,,655.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.0,,,percent of total billed charges,,,598.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX 3.5X16MM,10512569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX 3.5X16MM,10512569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ECHELON 10 STR TIP 150CM,10512575,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2995.00,898.50,1272.88,2545.75,,1850.91,,,percent of total billed charges,,,,,,,,service not payable,1461.56,,,percent of total billed charges,,,1510.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1272.88,,,percent of total billed charges,,,,,,,,,2246.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1497.5,,,percent of total billed charges,,,,,,,,service not payable,2246.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2545.75,,,percent of total billed charges,,,1377.7,,,percent of total billed charges,,,,,,,,,1946.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1946.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE GORILLA BOW ARROW 3MM,10512576,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4524.00,1357.20,1755.31,3845.40,,,,,,,,,,,,,,,,,,,,1755.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1922.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3845.40,,,percent of total billed charges,,,2035.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE GORILLA BOW ARROW 3MM,10512576,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4524.00,1357.20,1922.7,3845.40,,,,,,,,,,,,,service not payable,,,,,,,2281.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1922.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3845.40,,,percent of total billed charges,,,2081.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING PLATE 3.5X24MM,10512577,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING PLATE 3.5X24MM,10512577,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING PLATE 3.5X22MM,10512580,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING PLATE 3.5X22MM,10512580,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Complement Total CH50 (3002575),10512689,CDM,0300,RC,86162,CPT,,,,,,outpatient,facility,,,72.00,21.60,19.30,64.01,,64.01,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,19.91,,,fee schedule,,,47.77,,,fee schedule,,,42.38,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,42.06,,,fee schedule,,,19.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.31,,,fee schedule,,,45.92,,,fee schedule,,,,,,,,,19.91,,,fee schedule,,,,,,,,,26.12,,,fee schedule,,,41.45,,,fee schedule,,,54.0,,,percent of total billed charges,,,19.91,,,fee schedule,,,19.30,,,fee schedule,,,20.31,,,fee schedule,,,30.72,,,fee schedule,,,19.91,,,fee schedule,,,54.0,,,percent of total billed charges,,,,,,,,,20.31,,,fee schedule,,,,,,,,,61.20,,,percent of total billed charges,,,33.12,,,percent of total billed charges,,,,,,,,,22.35,,,fee schedule,,,19.91,,,fee schedule,,,,,,,,,19.71,,,fee schedule,,,19.91,,,fee schedule,,,,,,,,,20.11,,,fee schedule,,,,,,,,
Complement Total CH50 (3002575),10512689,CDM,0300,RC,86162,CPT,394,EAPG,,,,outpatient,facility,,,72.00,21.60,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Hemoglobin (HGB),10512691,CDM,0300,RC,83051,CPT,,,,,,outpatient,facility,,,71.00,21.30,6.94,60.35,,31.07,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.16,,,fee schedule,,,23.18,,,fee schedule,,,15.25,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,15.13,,,fee schedule,,,6.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.30,,,fee schedule,,,16.52,,,fee schedule,,,,,,,,,7.16,,,fee schedule,,,,,,,,,9.27,,,fee schedule,,,14.91,,,fee schedule,,,53.25,,,percent of total billed charges,,,7.16,,,fee schedule,,,6.94,,,fee schedule,,,7.30,,,fee schedule,,,10.91,,,fee schedule,,,7.16,,,fee schedule,,,53.25,,,percent of total billed charges,,,,,,,,,7.30,,,fee schedule,,,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,8.04,,,fee schedule,,,7.16,,,fee schedule,,,,,,,,,7.09,,,fee schedule,,,7.16,,,fee schedule,,,,,,,,,7.23,,,fee schedule,,,,,,,,
Plasma Hemoglobin (HGB),10512691,CDM,0300,RC,83051,CPT,402,EAPG,,,,outpatient,facility,,,71.00,21.30,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INF-Bladder Scan,10512761,CDM,0510,RC,51798,CPT,,,,,,outpatient,facility,,,175.00,52.50,80.5,148.75,,108.15,,,percent of total billed charges,,,,,,,,,85.40,,,percent of total billed charges,,,88.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,131.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,148.75,,,percent of total billed charges,,,80.5,,,percent of total billed charges,,,,,,,,,113.75,,,percent of total billed charges,,,,,,,,,,,,,,,113.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
INF-Bladder Scan,10512761,CDM,0510,RC,51798,CPT,05733,APC,,,,outpatient,facility,,,175.00,52.50,54.63,130.83,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,119.83,,,fee schedule,,,54.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",58.10,,,fee schedule,,,130.83,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,118.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,54.63,,,fee schedule,,,58.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,54.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",58.10,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,57.53,,,fee schedule,,,,,,,,
INF-Bladder Scan,10512761,CDM,0510,RC,51798,CPT,159,EAPG,,,,outpatient,facility,,,175.00,52.50,223.20,525.80,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.80,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,446.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.20,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,245.52,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ALLOGRAFT FEMORAL VEIN <21,10512792,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,13841.00,4152.30,5370.31,11764.85,,6782.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5813.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5370.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5882.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10380.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6920.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11764.85,,,percent of total billed charges,,,6228.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT FEMORAL VEIN <21,10512792,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,13841.00,4152.30,5813.22,11764.85,,6782.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5813.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6981.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5882.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10380.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6920.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10380.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11764.85,,,percent of total billed charges,,,6366.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SHT BLADE 6.5X55MM,10512794,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3856.00,1156.80,1496.13,3277.60,,,,,,,,,,,,,,,,,,,,1496.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.60,,,percent of total billed charges,,,1735.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SHT BLADE 6.5X55MM,10512794,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3856.00,1156.80,1638.8,3277.60,,,,,,,,,,,,,service not payable,,,,,,,1944.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3277.60,,,percent of total billed charges,,,1773.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN SHT BLADE 6.5X50MM,10512795,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3856.00,1156.80,1496.13,3277.60,,,,,,,,,,,,,,,,,,,,1496.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.60,,,percent of total billed charges,,,1735.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN SHT BLADE 6.5X50MM,10512795,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3856.00,1156.80,1638.8,3277.60,,,,,,,,,,,,,service not payable,,,,,,,1944.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1638.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2892.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1928.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2892.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3277.60,,,percent of total billed charges,,,1773.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 135D 11X135MM,10512797,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 135D 11X135MM,10512797,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD MODULAR - 32MM  3.0MM,10512798,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD MODULAR - 32MM  3.0MM,10512798,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 67.5 RT,10512799,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 67.5 RT,10512799,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET VIT HW G7 36MM,10512800,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET VIT HW G7 36MM,10512800,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CONICAL T15 3.5X 70MM,10512801,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1087.00,326.10,421.76,923.95,,,,,,,,,,,,,,,,,,,,421.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,815.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,543.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,923.95,,,percent of total billed charges,,,489.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CONICAL T15 3.5X 70MM,10512801,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1087.00,326.10,461.97,923.95,,,,,,,,,,,,,service not payable,,,,,,,548.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,461.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,815.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,543.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,815.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,923.95,,,percent of total billed charges,,,500.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CONICAL T15 3.5X 75MM,10512802,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1087.00,326.10,421.76,923.95,,,,,,,,,,,,,,,,,,,,421.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,815.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,543.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,923.95,,,percent of total billed charges,,,489.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CONICAL T15 3.5X 75MM,10512802,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1087.00,326.10,461.97,923.95,,,,,,,,,,,,,service not payable,,,,,,,548.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,461.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,815.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,543.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,815.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,923.95,,,percent of total billed charges,,,500.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP LKING T15 3.5X 65MM,10512803,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,998.00,299.40,387.22,848.30,,,,,,,,,,,,,,,,,,,,387.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,748.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,499.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,848.30,,,percent of total billed charges,,,449.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP LKING T15 3.5X 65MM,10512803,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,998.00,299.40,424.15,848.30,,,,,,,,,,,,,service not payable,,,,,,,503.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,424.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,748.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,499.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,748.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,848.30,,,percent of total billed charges,,,459.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 8H MED PROX RT 3.5X145MM,10512804,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6838.00,2051.40,2653.14,5812.30,,3350.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2871.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2653.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2906.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5128.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3419.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5812.30,,,percent of total billed charges,,,3077.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 8H MED PROX RT 3.5X145MM,10512804,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6838.00,2051.40,2871.96,5812.30,,3350.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2871.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3449.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2906.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5128.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3419.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5128.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5812.30,,,percent of total billed charges,,,3145.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 6H VAR ANG RT 3.5X117MM,10512805,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7290.00,2187.00,2828.52,6196.5,,3572.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3061.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2828.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5467.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3645.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6196.5,,,percent of total billed charges,,,3280.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 6H VAR ANG RT 3.5X117MM,10512805,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7290.00,2187.00,3061.80,6196.5,,3572.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3061.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3677.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3098.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5467.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3645.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5467.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6196.5,,,percent of total billed charges,,,3353.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAR ANG LKING 3.5X70MM,10512806,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAR ANG LKING 3.5X70MM,10512806,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Repair single transvenous electrode,10512938,CDM,0481,RC,33218,CPT,,,,,,outpatient,facility,,,5129.00,1538.70,2359.34,6509.0,,5129.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,2587.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,3846.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,3846.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4359.65,,,percent of total billed charges,,,2359.34,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Repair single transvenous electrode,10512938,CDM,0481,RC,33218,CPT,05221,APC,,,,outpatient,facility,,,5129.00,1538.70,3347.52,8015.59,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7341.71,,,fee schedule,,,3347.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3559.77,,,fee schedule,,,8015.59,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7235.31,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,3347.52,,,fee schedule,,,3559.77,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3347.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3559.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3524.73,,,fee schedule,,,,,,,,
Repair single transvenous electrode,10512938,CDM,0481,RC,33218,CPT,74,EAPG,,,,outpatient,facility,,,5129.00,1538.70,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW NAIL FEM 10.5X95MM,10512960,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NAIL FEM 10.5X95MM,10512960,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN LT 130D 360X11MM,10512961,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN LT 130D 360X11MM,10512961,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Comprehensive Electrophysiologic Study,10513077,CDM,0481,RC,93620,CPT,,,,,,outpatient,facility,,,8469.00,2540.70,3895.74,12795.0,,8469.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,4271.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,6351.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,6351.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7198.65,,,percent of total billed charges,,,3895.74,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Comprehensive Electrophysiologic Study,10513077,CDM,0481,RC,93620,CPT,05212,APC,,,,outpatient,facility,,,8469.00,2540.70,6979.74,16712.84,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,15307.77,,,fee schedule,,,6979.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7422.27,,,fee schedule,,,16712.84,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,15085.92,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,6979.74,,,fee schedule,,,7422.27,,,fee schedule,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,6979.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",7422.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,,,,,,,7276.74,,,fee schedule,,,,,,,,,7349.21,,,fee schedule,,,,,,,,
Comprehensive Electrophysiologic Study,10513077,CDM,0481,RC,93620,CPT,96,EAPG,,,,outpatient,facility,,,8469.00,2540.70,8469.0,18075.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18075.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,15364.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8469.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8469.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8469.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14048.58,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,15453.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BEARING KNEE TIBIAL 71-75X10MM,10513087,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE TIBIAL 71-75X10MM,10513087,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert Temporary Pacemaker Single Chamber,10514480,CDM,0481,RC,33210,CPT,,,,,,outpatient,facility,,,9835.00,2950.50,4524.10,12795.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert Temporary Pacemaker Single Chamber,10514480,CDM,0481,RC,33210,CPT,05222,APC,,,,outpatient,facility,,,9835.00,2950.50,7612.46,18227.89,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16695.46,,,fee schedule,,,7612.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8095.12,,,fee schedule,,,18227.89,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,16453.50,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,7612.46,,,fee schedule,,,8095.12,,,fee schedule,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,7612.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",8095.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,,,,,,,7936.39,,,fee schedule,,,,,,,,,8015.43,,,fee schedule,,,,,,,,
Insert Temporary Pacemaker Single Chamber,10514480,CDM,0481,RC,33210,CPT,74,EAPG,,,,outpatient,facility,,,9835.00,2950.50,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Pertussis Culture,10516,CDM,0300,RC,87070,CPT,,,,,,outpatient,facility,,,185.00,55.50,8.19,157.25,,36.60,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,8.45,,,fee schedule,,,27.31,,,fee schedule,,,17.97,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,17.84,,,fee schedule,,,8.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",8.62,,,fee schedule,,,19.48,,,fee schedule,,,,,,,,,8.45,,,fee schedule,,,,,,,,,10.96,,,fee schedule,,,17.58,,,fee schedule,,,138.75,,,percent of total billed charges,,,8.45,,,fee schedule,,,8.19,,,fee schedule,,,8.62,,,fee schedule,,,12.89,,,fee schedule,,,8.45,,,fee schedule,,,138.75,,,percent of total billed charges,,,,,,,,,8.62,,,fee schedule,,,,,,,,,157.25,,,percent of total billed charges,,,85.10,,,percent of total billed charges,,,,,,,,,9.48,,,fee schedule,,,8.45,,,fee schedule,,,,,,,,,8.36,,,fee schedule,,,8.45,,,fee schedule,,,,,,,,,8.54,,,fee schedule,,,,,,,,
Pertussis Culture,10516,CDM,0300,RC,87070,CPT,396,EAPG,,,,outpatient,facility,,,185.00,55.50,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW BONE POLYAXIAL 14X3.5MM,10516466,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLYAXIAL 14X3.5MM,10516466,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLYAXIAL 18X3.5MM,10516467,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLYAXIAL 18X3.5MM,10516467,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLYAXIAL 16X3.5MM,10516468,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLYAXIAL 16X3.5MM,10516468,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA 4X24MM,10516469,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA 4X24MM,10516469,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR IBALANCE RT SZ 2,10516470,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,15604.00,4681.20,6054.35,13263.4,,7645.96,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6553.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6054.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6631.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11703.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7802.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13263.4,,,percent of total billed charges,,,7021.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR IBALANCE RT SZ 2,10516470,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,15604.00,4681.20,6553.68,13263.4,,7645.96,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6553.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7870.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6631.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11703.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7802.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11703.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13263.4,,,percent of total billed charges,,,7177.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DOME PAT FEM 9X34MM,10516471,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3825.00,1147.50,1484.10,3251.25,,,,,,,,,,,,,,,,,,,,1484.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1625.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2868.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1912.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3251.25,,,percent of total billed charges,,,1721.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOME PAT FEM 9X34MM,10516471,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3825.00,1147.50,1625.62,3251.25,,,,,,,,,,,,,service not payable,,,,,,,1929.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1625.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2868.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1912.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2868.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3251.25,,,percent of total billed charges,,,1759.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID SHOULDER AEQUALIS S40,10516473,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5488.00,1646.40,2129.34,4664.80,,2689.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2304.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2129.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2332.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4116.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2744.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4664.80,,,percent of total billed charges,,,2469.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID SHOULDER AEQUALIS S40,10516473,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5488.00,1646.40,2304.96,4664.80,,2689.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2304.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2768.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2332.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4116.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2744.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4116.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4664.80,,,percent of total billed charges,,,2524.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD ES2 TITANIUM HEX 5.5X40MM,10516476,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1874.00,562.20,727.11,1592.90,,,,,,,,,,,,,,,,,,,,727.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1405.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,937.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1592.90,,,percent of total billed charges,,,843.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD ES2 TITANIUM HEX 5.5X40MM,10516476,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1874.00,562.20,796.45,1592.90,,,,,,,,,,,,,service not payable,,,,,,,945.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,796.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1405.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,937.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1405.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1592.90,,,percent of total billed charges,,,862.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CTX T8 ST 2.7X10MM,10516478,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,189.00,56.70,73.33,160.65,,,,,,,,,,,,,,,,,,,,73.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.65,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CTX T8 ST 2.7X10MM,10516478,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,189.00,56.70,80.33,160.65,,,,,,,,,,,,,service not payable,,,,,,,95.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,80.33,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,160.65,,,percent of total billed charges,,,86.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CTX T8 ST 2.7X12MM,10516479,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,188.00,56.40,72.94,159.80,,,,,,,,,,,,,,,,,,,,72.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,141.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.80,,,percent of total billed charges,,,84.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CTX T8 ST 2.7X12MM,10516479,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,188.00,56.40,79.90,159.80,,,,,,,,,,,,,service not payable,,,,,,,94.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,79.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,141.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,94.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,141.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,159.80,,,percent of total billed charges,,,86.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Renal Biopsy Percutaneous,10516546,CDM,0361,RC,50200,CPT,,,,,,outpatient,facility,,,2900.00,870.00,1334.0,3044.0,,2900.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1462.76,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,2175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,2175.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2465.0,,,percent of total billed charges,,,1334.0,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Renal Biopsy Percutaneous,10516546,CDM,0361,RC,50200,CPT,05072,APC,,,,outpatient,facility,,,2900.00,870.00,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
Renal Biopsy Percutaneous,10516546,CDM,0361,RC,50200,CPT,170,EAPG,,,,outpatient,facility,,,2900.00,870.00,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM FEMORAL MEDIUM,10516693,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL MEDIUM,10516693,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIO CHIPS CANCELLOUS 15CC,10516695,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,1294.00,388.20,502.07,1099.90,,,,,,,,,,,,,,,,,,,,502.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,970.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,647.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1099.90,,,percent of total billed charges,,,582.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIO CHIPS CANCELLOUS 15CC,10516695,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,1294.00,388.20,549.95,1099.90,,,,,,,,,,,,,service not payable,,,,,,,652.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,549.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,970.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,647.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,970.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1099.90,,,percent of total billed charges,,,595.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BIO CHIPS CANCELLOUS 15CC,10516695,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,1294.00,388.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM ATTUNE CEM SZ3 L,10516697,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM ATTUNE CEM SZ3 L,10516697,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB AOX RP ATTUNE SZ3,10516698,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB AOX RP ATTUNE SZ3,10516698,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP BI MENTUM PFRK PFIT 49MM,10516699,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP BI MENTUM PFRK PFIT 49MM,10516699,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET BI MENTUM 28X49MM,10516700,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET BI MENTUM 28X49MM,10516700,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP BI MENTUM PFRK PFIT 51MM,10516701,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP BI MENTUM PFRK PFIT 51MM,10516701,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET BI MENTUM 28X51MM,10516702,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET BI MENTUM 28X51MM,10516702,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS ROD TENDON 6MMX25CM,10516703,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5389.00,1616.70,2090.93,4580.65,,2640.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2263.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2090.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2290.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4041.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4580.65,,,percent of total billed charges,,,2425.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS ROD TENDON 6MMX25CM,10516703,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5389.00,1616.70,2263.38,4580.65,,2640.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2263.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2718.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2290.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4041.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4041.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4580.65,,,percent of total billed charges,,,2478.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 6FR 10CM,10516704,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,75.00,22.50,31.88,63.75,,46.35,,,percent of total billed charges,,,,,,,,service not payable,36.60,,,percent of total billed charges,,,37.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,31.88,,,percent of total billed charges,,,,,,,,,56.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,37.5,,,percent of total billed charges,,,,,,,,service not payable,56.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,63.75,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,48.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB UNI SZ3-4 LM/RL 9MM,10516705,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB UNI SZ3-4 LM/RL 9MM,10516705,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NARROW RT SZ 5,10516706,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12145.00,3643.50,4712.26,10323.25,,5951.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5100.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4712.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5161.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9108.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6072.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10323.25,,,percent of total billed charges,,,5465.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NARROW RT SZ 5,10516706,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12145.00,3643.50,5100.90,10323.25,,5951.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5100.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6125.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5161.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6072.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10323.25,,,percent of total billed charges,,,5586.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ C RIGHT,10516707,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5295.00,1588.50,2054.46,4500.75,,2594.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2223.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2054.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2250.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3971.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2647.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4500.75,,,percent of total billed charges,,,2382.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ C RIGHT,10516707,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5295.00,1588.50,2223.90,4500.75,,2594.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2223.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2670.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2250.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3971.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2647.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3971.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4500.75,,,percent of total billed charges,,,2435.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FIXED RT 4-5 CD 12MM,10516708,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4819.00,1445.70,1869.77,4096.15,,,,,,,,,,,,,,,,,,,,1869.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2048.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3614.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2409.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4096.15,,,percent of total billed charges,,,2168.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FIXED RT 4-5 CD 12MM,10516708,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4819.00,1445.70,2048.07,4096.15,,,,,,,,,,,,,service not payable,,,,,,,2430.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2048.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3614.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2409.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3614.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4096.15,,,percent of total billed charges,,,2216.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG BONE INTRAMEDULLARY XL 26,10516709,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG BONE INTRAMEDULLARY XL 26,10516709,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 14X122MM,10516710,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15080.00,4524.00,5851.04,12818.0,,7389.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6333.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5851.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6409.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11310.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7540.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12818.0,,,percent of total billed charges,,,6786.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 14X122MM,10516710,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15080.00,4524.00,6333.60,12818.0,,7389.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6333.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7606.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6409.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11310.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7540.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11310.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12818.0,,,percent of total billed charges,,,6936.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER BI-V QUAD CRT-P IS-4,10516712,CDM,0278,RC,C2621,HCPCS,,,,,,inpatient,facility,,,20683.00,6204.90,8025.00,17580.55,,10134.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8686.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8025.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8790.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17580.55,,,percent of total billed charges,,,9307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER BI-V QUAD CRT-P IS-4,10516712,CDM,0278,RC,C2621,HCPCS,,,,,,outpatient,facility,,,20683.00,6204.90,8686.86,17580.55,,10134.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8686.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10432.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8790.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17580.55,,,percent of total billed charges,,,9514.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LATERAL DIST 8H 132MM RT,10518004,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3126.00,937.80,1212.89,2657.10,,,,,,,,,,,,,,,,,,,,1212.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1328.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2344.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1563.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2657.10,,,percent of total billed charges,,,1406.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LATERAL DIST 8H 132MM RT,10518004,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3126.00,937.80,1328.55,2657.10,,,,,,,,,,,,,service not payable,,,,,,,1576.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1328.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2344.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1563.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2344.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2657.10,,,percent of total billed charges,,,1437.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX PERM 10X12 CM,10518006,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX PERM 10X12 CM,10518006,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX RESORB 10X12 CM,10518007,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX RESORB 10X12 CM,10518007,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX PERM 6X10 CM,10518008,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2491.00,747.30,966.51,2117.35,,,,,,,,,,,,,,,,,,,,966.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1868.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2117.35,,,percent of total billed charges,,,1120.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX PERM 6X10 CM,10518008,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2491.00,747.30,1058.68,2117.35,,,,,,,,,,,,,service not payable,,,,,,,1256.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1058.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1868.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2117.35,,,percent of total billed charges,,,1145.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX RESORB 6X10 CM,10518009,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2491.00,747.30,966.51,2117.35,,,,,,,,,,,,,,,,,,,,966.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1868.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1245.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2117.35,,,percent of total billed charges,,,1120.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX RESORB 6X10 CM,10518009,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2491.00,747.30,1058.68,2117.35,,,,,,,,,,,,,service not payable,,,,,,,1256.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1058.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1868.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1245.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1868.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2117.35,,,percent of total billed charges,,,1145.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX PERM 1S 10X12 CM,10518010,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,6373.00,1911.90,2472.72,5417.05,,3122.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2676.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2472.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2708.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4779.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3186.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5417.05,,,percent of total billed charges,,,2867.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX PERM 1S 10X12 CM,10518010,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,6373.00,1911.90,2676.66,5417.05,,3122.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2676.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3214.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2708.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4779.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3186.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4779.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5417.05,,,percent of total billed charges,,,2931.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX RESB 1S 10X12 CM,10518011,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,6373.00,1911.90,2472.72,5417.05,,3122.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2676.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2472.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2708.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4779.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3186.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5417.05,,,percent of total billed charges,,,2867.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX RESB 1S 10X12 CM,10518011,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,6373.00,1911.90,2676.66,5417.05,,3122.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2676.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3214.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2708.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4779.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3186.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4779.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5417.05,,,percent of total billed charges,,,2931.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX PERM 1S 6X10 CM,10518012,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4249.00,1274.70,1648.61,3611.65,,,,,,,,,,,,,,,,,,,,1648.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3611.65,,,percent of total billed charges,,,1912.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX PERM 1S 6X10 CM,10518012,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4249.00,1274.70,1805.82,3611.65,,,,,,,,,,,,,service not payable,,,,,,,2143.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3611.65,,,percent of total billed charges,,,1954.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE OVITEX RESRB 1S 6X10 CM,10518013,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4249.00,1274.70,1648.61,3611.65,,,,,,,,,,,,,,,,,,,,1648.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3611.65,,,percent of total billed charges,,,1912.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE OVITEX RESRB 1S 6X10 CM,10518013,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4249.00,1274.70,1805.82,3611.65,,,,,,,,,,,,,service not payable,,,,,,,2143.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1805.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3186.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2124.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3186.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3611.65,,,percent of total billed charges,,,1954.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 300CC,10518014,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 300CC,10518014,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2.7MM COMP 8H 67MM,10518016,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1457.00,437.10,565.32,1238.45,,,,,,,,,,,,,,,,,,,,565.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1092.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1238.45,,,percent of total billed charges,,,655.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2.7MM COMP 8H 67MM,10518016,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1457.00,437.10,619.23,1238.45,,,,,,,,,,,,,service not payable,,,,,,,734.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,619.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1092.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,728.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1092.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1238.45,,,percent of total billed charges,,,670.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3.5MM COMP 7H 90MM,10518017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1610.00,483.00,624.68,1368.5,,,,,,,,,,,,,,,,,,,,624.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1207.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,805.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1368.5,,,percent of total billed charges,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3.5MM COMP 7H 90MM,10518017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1610.00,483.00,684.25,1368.5,,,,,,,,,,,,,service not payable,,,,,,,812.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,684.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1207.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,805.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1207.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1368.5,,,percent of total billed charges,,,740.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAP EVOS 3.5MM W/AO QC,10518018,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,878.00,263.40,340.66,746.30,,,,,,,,,,,,,,,,,,,,340.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,658.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,439.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.30,,,percent of total billed charges,,,395.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAP EVOS 3.5MM W/AO QC,10518018,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,878.00,263.40,373.15,746.30,,,,,,,,,,,,,service not payable,,,,,,,442.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,373.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,658.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,439.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,658.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,746.30,,,percent of total billed charges,,,403.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 8FR 18G 25CM X_PLS-2508 X_MERIT,10518019,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,152.65,,,percent of total billed charges,,,,,,,,service not payable,120.54,,,percent of total billed charges,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,160.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 5F 0.014INX4X210MMX150CM,10518022,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,1452.3,,,percent of total billed charges,,,,,,,,service not payable,1146.8,,,percent of total billed charges,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1527.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHAMBER 6X12.5MM 13.0,10518023,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHAMBER 6X12.5MM 13.0,10518023,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PCI Exam,10518541,CDM,0402,RC,76831,CPT,,,,,,outpatient,facility,,,716.00,214.80,174.40,608.60,,233.73,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,174.40,,,fee schedule,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,513.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PCI Exam,10518541,CDM,0402,RC,76831,CPT,05523,APC,,,,outpatient,facility,,,716.00,214.80,222.34,532.39,,,,,,,,231.80,,,fee schedule,,,,,,,,,,,,,,,487.63,,,fee schedule,,,222.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",236.44,,,fee schedule,,,532.39,,,fee schedule,,,,,,,,,231.80,,,fee schedule,,,,,,,,,,,,,,,480.56,,,fee schedule,,,,,,,,,231.80,,,fee schedule,,,222.34,,,fee schedule,,,236.44,,,fee schedule,,,,,,,,,231.80,,,fee schedule,,,,,,,,,222.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",236.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.80,,,fee schedule,,,,,,,,,,,,,,,231.80,,,fee schedule,,,,,,,,,234.11,,,fee schedule,,,,,,,,
PCI Exam,10518541,CDM,0402,RC,76831,CPT,289,EAPG,,,,outpatient,facility,,,716.00,214.80,244.92,545.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,463.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,244.92,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,326.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,359.41,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TRAY TIBIAL KNEE CEMENTED 75MM,10518560,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL KNEE CEMENTED 75MM,10518560,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL KNEE CEMENTED 67MM,10518561,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL KNEE CEMENTED 67MM,10518561,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HANDPIECE BX DEVICE DISP 9G 12CMX20MM X_ATEC 0912-,10518562,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1137.00,341.10,441.16,966.45,,,,,,,,,,,,,,,,,,,,441.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,852.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.45,,,percent of total billed charges,,,511.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE BX DEVICE DISP 9G 12CMX20MM X_ATEC 0912-,10518562,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1137.00,341.10,483.22,966.45,,,,,,,,,,,,,service not payable,,,,,,,573.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,483.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,852.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,568.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,852.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,966.45,,,percent of total billed charges,,,523.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HANDPIECE 12CMX20MM,10518563,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1137.00,341.10,441.16,966.45,,,,,,,,,,,,,,,,,,,,441.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,852.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.45,,,percent of total billed charges,,,511.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE 12CMX20MM,10518563,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1137.00,341.10,483.22,966.45,,,,,,,,,,,,,service not payable,,,,,,,573.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,483.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,852.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,568.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,852.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,966.45,,,percent of total billed charges,,,523.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BX SITE TRIMARK-13 2S,10518564,CDM,0270,RC,A4648,HCPCS,,,,,,outpatient,facility,,,351.00,105.30,149.18,298.35,,216.92,,,percent of total billed charges,,,,,,,,service not payable,171.29,,,percent of total billed charges,,,177.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,149.18,,,percent of total billed charges,,,,,,,,,263.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,175.5,,,percent of total billed charges,,,,,,,,service not payable,263.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,298.35,,,percent of total billed charges,,,161.46,,,percent of total billed charges,,,,,,,,,228.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,228.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA NEXGEN 10X32MM,10518569,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA NEXGEN 10X32MM,10518569,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE LT TIB EF 14MM,10518570,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4819.00,1445.70,1869.77,4096.15,,,,,,,,,,,,,,,,,,,,1869.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2048.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3614.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2409.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4096.15,,,percent of total billed charges,,,2168.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE LT TIB EF 14MM,10518570,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4819.00,1445.70,2048.07,4096.15,,,,,,,,,,,,,service not payable,,,,,,,2430.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2048.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3614.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2409.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3614.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4096.15,,,percent of total billed charges,,,2216.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE NRW LT SZ 9.0,10518571,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15261.00,4578.30,5921.27,12971.85,,7477.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6409.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5921.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6485.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11445.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7630.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12971.85,,,percent of total billed charges,,,6867.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE NRW LT SZ 9.0,10518571,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15261.00,4578.30,6409.62,12971.85,,7477.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6409.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7697.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6485.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11445.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7630.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11445.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12971.85,,,percent of total billed charges,,,7020.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED LT SZ E,10518572,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6852.00,2055.60,2658.58,5824.20,,3357.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2877.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2658.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5139.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3426.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5824.20,,,percent of total billed charges,,,3083.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED LT SZ E,10518572,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6852.00,2055.60,2877.84,5824.20,,3357.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2877.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3456.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5139.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3426.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5139.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5824.20,,,percent of total billed charges,,,3151.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 62.5MM LT,10518573,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 62.5MM LT,10518573,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING INSERT MLAP 10X63-67MM,10518574,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING INSERT MLAP 10X63-67MM,10518574,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM G7 ACETAB 36MM  3MM,10518575,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM G7 ACETAB 36MM  3MM,10518575,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL G7 LMTD HOLE SZ F 56MM,10518576,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL G7 LMTD HOLE SZ F 56MM,10518576,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HANDPIECE NANOSCOPE CAMERA,10518578,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2880.00,864.00,1117.44,2448.0,,,,,,,,,,,,,,,,,,,,1117.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2160.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2448.0,,,percent of total billed charges,,,1296.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE NANOSCOPE CAMERA,10518578,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2880.00,864.00,1224.0,2448.0,,,,,,,,,,,,,service not payable,,,,,,,1452.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2160.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2160.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2448.0,,,percent of total billed charges,,,1324.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG LOCKING T8 2.0X20MM,10518580,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1232.00,369.60,478.02,1047.2,,,,,,,,,,,,,,,,,,,,478.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,924.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,616.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.2,,,percent of total billed charges,,,554.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG LOCKING T8 2.0X20MM,10518580,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1232.00,369.60,523.60,1047.2,,,,,,,,,,,,,service not payable,,,,,,,621.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,523.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,924.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,616.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,924.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1047.2,,,percent of total billed charges,,,566.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL 43X16MM,10518581,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11779.00,3533.70,4570.25,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4570.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10012.15,,,percent of total billed charges,,,5300.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL 43X16MM,10518581,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11779.00,3533.70,4947.18,10012.15,,5771.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4947.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5941.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5006.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8834.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5889.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8834.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10012.15,,,percent of total billed charges,,,5418.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KNEE ORTHOSIS W/ ADJ JOINT RT,10518582,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2489.00,746.70,965.73,2115.65,,,,,,,,,,,,,,,,,,,,965.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1057.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1866.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1244.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2115.65,,,percent of total billed charges,,,1120.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KNEE ORTHOSIS W/ ADJ JOINT RT,10518582,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2489.00,746.70,1057.82,2115.65,,,,,,,,,,,,,service not payable,,,,,,,1255.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1057.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1866.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1244.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1866.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2115.65,,,percent of total billed charges,,,1144.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLN PTA VIATRAC 4X20X80,10518584,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLN PTA VIATRAC 6X20X80,10518585,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLN PTA VIATRAC 7X20X80,10518586,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,658.79,,,percent of total billed charges,,,,,,,,service not payable,520.21,,,percent of total billed charges,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,692.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM SIGMA CEMENTED,10518587,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM SIGMA CEMENTED,10518587,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFN-ADV LT 130D 380X10MM,10518588,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFN-ADV LT 130D 380X10MM,10518588,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON PATELLA 3PEG 40X10MM,10518589,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUTTON PATELLA 3PEG 40X10MM,10518589,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 72.5 RT,10518590,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 72.5 RT,10518590,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB VANG 71-75X14MM,10518591,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB VANG 71-75X14MM,10518591,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM OFFSET 16X160MM,10520624,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM OFFSET 16X160MM,10520624,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DEMIN CAN FD 15CC,10520625,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5572.00,1671.60,2161.94,4736.20,,2730.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2340.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2161.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4179.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2786.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4736.20,,,percent of total billed charges,,,2507.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE DEMIN CAN FD 15CC,10520625,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5572.00,1671.60,2340.24,4736.20,,2730.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2340.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2810.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4179.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2786.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4179.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4736.20,,,percent of total billed charges,,,2563.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HANDPIECE 12MM,10520626,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,3410.00,1023.00,1323.08,2898.5,,,,,,,,,,,,,,,,,,,,1323.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2557.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2898.5,,,percent of total billed charges,,,1534.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE 12MM,10520626,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,3410.00,1023.00,1449.25,2898.5,,,,,,,,,,,,,service not payable,,,,,,,1720.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1449.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2557.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2557.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2898.5,,,percent of total billed charges,,,1568.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BIOPSY BRST ATEC 13-09,10520627,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BIOPSY BRST ATEC 13-09,10520627,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST ATEC 2ND SHAPE,10520628,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BRST ATEC 2ND SHAPE,10520628,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST TITANIUM 1ST SHAPE,10520629,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BRST TITANIUM 1ST SHAPE,10520629,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST TITANIUM 2ND SHAPE,10520630,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BRST TITANIUM 2ND SHAPE,10520630,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST TITANIUM MINI-CORK,10520631,CDM,0270,RC,A4648,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,229.90,,,percent of total billed charges,,,,,,,,service not payable,181.54,,,percent of total billed charges,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.0,,,percent of total billed charges,,,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,241.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,241.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING STARDRV 2.4X11MM,10520632,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,927.00,278.10,359.68,787.95,,,,,,,,,,,,,,,,,,,,359.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,393.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,695.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,463.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.95,,,percent of total billed charges,,,417.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING STARDRV 2.4X11MM,10520632,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,927.00,278.10,393.97,787.95,,,,,,,,,,,,,service not payable,,,,,,,467.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,393.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,695.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,463.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,695.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,787.95,,,percent of total billed charges,,,426.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 6H STR 2.4X52MM X_249.676 X_DEPUY SYNTHE,10520633,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2465.00,739.50,956.42,2095.25,,,,,,,,,,,,,,,,,,,,956.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1848.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2095.25,,,percent of total billed charges,,,1109.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 6H STR 2.4X52MM X_249.676 X_DEPUY SYNTHE,10520633,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2465.00,739.50,1047.62,2095.25,,,,,,,,,,,,,service not payable,,,,,,,1243.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1047.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1848.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1848.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2095.25,,,percent of total billed charges,,,1133.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 6H STR 2.7X58MM,10520634,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2601.00,780.30,1009.19,2210.85,,,,,,,,,,,,,,,,,,,,1009.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2210.85,,,percent of total billed charges,,,1170.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 6H STR 2.7X58MM,10520634,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,,,,,,,,,,,,service not payable,,,,,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM OXIN JRNY SZ2 LM/RL,10520698,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6105.00,1831.50,2368.74,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5189.25,,,percent of total billed charges,,,2747.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM OXIN JRNY SZ2 LM/RL,10520698,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6105.00,1831.50,2564.10,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3079.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5189.25,,,percent of total billed charges,,,2808.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB UNI JRNY SZ2 LM/RL,10520699,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4284.00,1285.20,1662.19,3641.40,,,,,,,,,,,,,,,,,,,,1662.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3641.40,,,percent of total billed charges,,,1927.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB UNI JRNY SZ2 LM/RL,10520699,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4284.00,1285.20,1820.7,3641.40,,,,,,,,,,,,,service not payable,,,,,,,2160.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1820.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3213.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2142.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3213.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3641.40,,,percent of total billed charges,,,1970.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB UNI JRNY SZ1-2 LM/RL,10520700,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB UNI JRNY SZ1-2 LM/RL,10520700,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL X3 SZ 7 11MM,10520701,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL X3 SZ 7 11MM,10520701,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATO POLYAX 5.5X40MM,10520705,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO POLYAX 5.5X40MM,10520705,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE ILIUM TRICORTICAL 9 13MM,10520707,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4033.00,1209.90,1564.80,3428.05,,,,,,,,,,,,,,,,,,,,1564.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1714.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3024.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2016.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3428.05,,,percent of total billed charges,,,1814.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE ILIUM TRICORTICAL 9 13MM,10520707,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4033.00,1209.90,1714.02,3428.05,,,,,,,,,,,,,service not payable,,,,,,,2034.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1714.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3024.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2016.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3024.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3428.05,,,percent of total billed charges,,,1855.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 3.2MM 1.6MM TIP,10520708,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,508.00,152.40,215.90,431.80,,313.94,,,percent of total billed charges,,,,,,,,service not payable,247.90,,,percent of total billed charges,,,256.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,215.90,,,percent of total billed charges,,,,,,,,,381.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,254.0,,,percent of total billed charges,,,,,,,,service not payable,381.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,431.80,,,percent of total billed charges,,,233.68,,,percent of total billed charges,,,,,,,,,330.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,330.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE STEMMED FLTD SZ 3,10520709,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE STEMMED FLTD SZ 3,10520709,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS-FLEX GSF LT SZ D,10520710,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS-FLEX GSF LT SZ D,10520710,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LPS MOBILE D 3- 5 10MM,10520711,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LPS MOBILE D 3- 5 10MM,10520711,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FFP P4 Thaw E4725/Spl,10522480,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,205.0,,30.28,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
FFP P4 Thaw E4725/Spl,10522480,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,49.00,14.70,49.0,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,49.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,49.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
FFP P4 Thaw E4725/Spl,10522480,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
FFP P4 Thaw E4725,10522482,CDM,0390,RC,P9017,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,205.0,,66.13,,,percent of total billed charges,,,,,,,,,52.22,,,percent of total billed charges,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
FFP P4 Thaw E4725,10522482,CDM,0390,RC,P9017,HCPCS,09508,APC,,,,outpatient,facility,,,107.00,32.10,77.53,190.50,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,174.48,,,fee schedule,,,77.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.60,,,fee schedule,,,190.50,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,171.95,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,77.53,,,fee schedule,,,84.60,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,77.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",84.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,83.76,,,fee schedule,,,,,,,,
FFP P4 Thaw E4725,10522482,CDM,0390,RC,P9017,HCPCS,2061,EAPG,,,,outpatient,facility,,,107.00,32.10,107.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Blood Adm Fee,105225,CDM,0391,RC,36430,CPT,,,,,,outpatient,facility,,,1278.00,383.40,180.0,1086.3,,789.80,,,percent of total billed charges,,,,,,,,,623.66,,,percent of total billed charges,,,644.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,543.15,,,percent of total billed charges,,,,,,,,,958.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,639.0,,,percent of total billed charges,,,,,,,,,958.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1086.3,,,percent of total billed charges,,,587.88,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Blood Adm Fee,105225,CDM,0391,RC,36430,CPT,05241,APC,,,,outpatient,facility,,,1278.00,383.40,402.13,962.90,,,,,,,,419.24,,,fee schedule,,,,,,,,,,,,,,,881.94,,,fee schedule,,,402.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",427.62,,,fee schedule,,,962.90,,,fee schedule,,,,,,,,,419.24,,,fee schedule,,,,,,,,,,,,,,,869.16,,,fee schedule,,,,,,,,,419.24,,,fee schedule,,,402.13,,,fee schedule,,,427.62,,,fee schedule,,,,,,,,,419.24,,,fee schedule,,,,,,,,,402.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",427.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.24,,,fee schedule,,,,,,,,,,,,,,,419.24,,,fee schedule,,,,,,,,,423.42,,,fee schedule,,,,,,,,
Blood Adm Fee,105225,CDM,0391,RC,36430,CPT,113,EAPG,,,,outpatient,facility,,,1278.00,383.40,313.10,1604.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1363.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.53,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,587.53,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,587.53,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,313.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,344.41,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bill EKB,105235,CDM,0300,RC,87184,CPT,,,,,,outpatient,facility,,,86.00,25.80,7.11,73.10,,29.32,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.33,,,fee schedule,,,21.88,,,fee schedule,,,15.6,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,15.48,,,fee schedule,,,7.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.48,,,fee schedule,,,16.90,,,fee schedule,,,,,,,,,7.33,,,fee schedule,,,,,,,,,9.69,,,fee schedule,,,15.26,,,fee schedule,,,64.5,,,percent of total billed charges,,,7.33,,,fee schedule,,,7.11,,,fee schedule,,,7.48,,,fee schedule,,,11.4,,,fee schedule,,,7.33,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,7.48,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,8.23,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.26,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.40,,,fee schedule,,,,,,,,
Bill EKB,105235,CDM,0300,RC,87184,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bill EMIC,105236,CDM,0300,RC,87181,CPT,,,,,,outpatient,facility,,,86.00,25.80,4.51,73.10,,20.17,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,4.65,,,fee schedule,,,15.05,,,fee schedule,,,9.90,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,9.83,,,fee schedule,,,4.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",4.74,,,fee schedule,,,10.73,,,fee schedule,,,,,,,,,4.65,,,fee schedule,,,,,,,,,6.31,,,fee schedule,,,9.69,,,fee schedule,,,64.5,,,percent of total billed charges,,,4.65,,,fee schedule,,,4.51,,,fee schedule,,,4.74,,,fee schedule,,,7.43,,,fee schedule,,,4.65,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,4.74,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,5.23,,,fee schedule,,,4.65,,,fee schedule,,,,,,,,,4.61,,,fee schedule,,,4.65,,,fee schedule,,,,,,,,,4.70,,,fee schedule,,,,,,,,
Bill EMIC,105236,CDM,0300,RC,87181,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Bill KB,105237,CDM,0300,RC,87184,CPT,,,,,,outpatient,facility,,,86.00,25.80,7.11,73.10,,29.32,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,7.33,,,fee schedule,,,21.88,,,fee schedule,,,15.6,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,15.48,,,fee schedule,,,7.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",7.48,,,fee schedule,,,16.90,,,fee schedule,,,,,,,,,7.33,,,fee schedule,,,,,,,,,9.69,,,fee schedule,,,15.26,,,fee schedule,,,64.5,,,percent of total billed charges,,,7.33,,,fee schedule,,,7.11,,,fee schedule,,,7.48,,,fee schedule,,,11.4,,,fee schedule,,,7.33,,,fee schedule,,,64.5,,,percent of total billed charges,,,,,,,,,7.48,,,fee schedule,,,,,,,,,73.10,,,percent of total billed charges,,,39.56,,,percent of total billed charges,,,,,,,,,8.23,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.26,,,fee schedule,,,7.33,,,fee schedule,,,,,,,,,7.40,,,fee schedule,,,,,,,,
Bill KB,105237,CDM,0300,RC,87184,CPT,396,EAPG,,,,outpatient,facility,,,86.00,25.80,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 95992 Canalith Repositioning,10524759,CDM,0420,RC,95992,CPT,,,,,GP  ,outpatient,facility,,,120.00,36.00,38.46,260.0,,74.16,,,percent of total billed charges,,,38.54,,,fee schedule,,,58.56,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,81.08,,,fee schedule,,,38.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",39.23,,,fee schedule,,,88.34,,,fee schedule,,,,,,,,,38.46,,,fee schedule,,,,,,,,,173.0,,,per diem,,,79.91,,,fee schedule,,,90.0,,,percent of total billed charges,,,38.54,,,fee schedule,,,38.84,,,fee schedule,,,39.31,,,fee schedule,,,204.0,,,per diem,,,38.46,,,fee schedule,,,90.0,,,percent of total billed charges,,,38.84,,,fee schedule,,,39.31,,,fee schedule,,,,,,,,,102.0,,,percent of total billed charges,,,55.20,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,38.46,,,fee schedule,,,,,,,,,229.0,,,per diem,,,38.54,,,fee schedule,,,,,,,,,38.54,,,fee schedule,,,,,,,,
PT 95992 Canalith Repositioning,10524759,CDM,0420,RC,95992,CPT,269,EAPG,,,GP  ,outpatient,facility,,,120.00,36.00,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97598 Selective Debridement >20cm,10524761,CDM,0420,RC,97598,CPT,,,,,GP  ,outpatient,facility,,,341.00,102.30,39.46,289.85,,210.74,,,percent of total billed charges,,,39.60,,,fee schedule,,,166.41,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,83.30,,,fee schedule,,,,,,,,,40.25,,,fee schedule,,,90.63,,,fee schedule,,,,,,,,,39.46,,,fee schedule,,,,,,,,,173.0,,,per diem,,,82.09,,,fee schedule,,,255.75,,,percent of total billed charges,,,39.60,,,fee schedule,,,,,,,,,40.39,,,fee schedule,,,204.0,,,per diem,,,39.46,,,fee schedule,,,255.75,,,percent of total billed charges,,,40.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",40.39,,,fee schedule,,,,,,,,,289.85,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,39.46,,,fee schedule,,,,,,,,,229.0,,,per diem,,,39.60,,,fee schedule,,,,,,,,,39.60,,,fee schedule,,,,,,,,
PT 97598 Selective Debridement >20cm,10524761,CDM,0420,RC,97598,CPT,18,EAPG,,,GP  ,outpatient,facility,,,341.00,102.30,341.0,6298.20,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6298.20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5353.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,341.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2903.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3193.81,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97597 Selective Debridement</ 20cm,10524765,CDM,0420,RC,97597,CPT,,,,,GP  ,outpatient,facility,,,341.00,102.30,88.29,289.85,,210.74,,,percent of total billed charges,,,88.29,,,fee schedule,,,166.41,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,185.74,,,fee schedule,,,,,,,,,90.09,,,fee schedule,,,202.86,,,fee schedule,,,,,,,,,88.32,,,fee schedule,,,,,,,,,173.0,,,per diem,,,183.05,,,fee schedule,,,255.75,,,percent of total billed charges,,,88.29,,,fee schedule,,,,,,,,,90.06,,,fee schedule,,,204.0,,,per diem,,,88.32,,,fee schedule,,,255.75,,,percent of total billed charges,,,89.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",90.06,,,fee schedule,,,,,,,,,289.85,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,88.32,,,fee schedule,,,,,,,,,229.0,,,per diem,,,88.29,,,fee schedule,,,,,,,,,88.29,,,fee schedule,,,,,,,,
PT 97597 Selective Debridement</ 20cm,10524765,CDM,0420,RC,97597,CPT,16,EAPG,,,GP  ,outpatient,facility,,,341.00,102.30,265.17,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,265.17,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT G0281 E-Stim Unattended for Wounds,10524769,CDM,0420,RC,G0281,HCPCS,,,,,GP  ,outpatient,facility,,,73.00,21.90,10.5,260.0,,45.11,,,percent of total billed charges,,,10.53,,,fee schedule,,,35.62,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,22.15,,,fee schedule,,,12.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.71,,,fee schedule,,,24.11,,,fee schedule,,,,,,,,,10.5,,,fee schedule,,,,,,,,,173.0,,,per diem,,,21.83,,,fee schedule,,,54.75,,,percent of total billed charges,,,10.53,,,fee schedule,,,12.05,,,fee schedule,,,10.74,,,fee schedule,,,204.0,,,per diem,,,10.5,,,fee schedule,,,54.75,,,percent of total billed charges,,,12.05,,,fee schedule,,,10.74,,,fee schedule,,,,,,,,,62.05,,,percent of total billed charges,,,33.58,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,10.5,,,fee schedule,,,,,,,,,229.0,,,per diem,,,10.53,,,fee schedule,,,,,,,,,10.53,,,fee schedule,,,,,,,,
PT G0281 E-Stim Unattended for Wounds,10524769,CDM,0420,RC,G0281,HCPCS,16,EAPG,,,GP  ,outpatient,facility,,,73.00,21.90,73.0,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,73.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,73.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97542 Wheelchair Management,10524773,CDM,0420,RC,97542,CPT,,,,,GP  ,outpatient,facility,,,137.00,41.10,23.44,260.0,,91.65,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,28.79,,,fee schedule,,,68.39,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,60.57,,,fee schedule,,,23.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",29.38,,,fee schedule,,,66.15,,,fee schedule,,,,,,,,,28.80,,,fee schedule,,,,,,,,,173.0,,,per diem,,,59.69,,,fee schedule,,,102.75,,,percent of total billed charges,,,28.79,,,fee schedule,,,23.44,,,fee schedule,,,29.37,,,fee schedule,,,204.0,,,per diem,,,28.80,,,fee schedule,,,102.75,,,percent of total billed charges,,,23.44,,,fee schedule,,,29.37,,,fee schedule,,,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,28.80,,,fee schedule,,,,,,,,,229.0,,,per diem,,,28.79,,,fee schedule,,,,,,,,,28.79,,,fee schedule,,,,,,,,
PT 97542 Wheelchair Management,10524773,CDM,0420,RC,97542,CPT,269,EAPG,,,GP  ,outpatient,facility,,,137.00,41.10,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT G0281 E-Stim Unattended for Wounds,10524826,CDM,0430,RC,G0281,HCPCS,,,,,GO  ,outpatient,facility,,,73.00,21.90,10.5,260.0,,45.11,,,percent of total billed charges,,,10.53,,,fee schedule,,,35.62,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,22.15,,,fee schedule,,,12.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10.71,,,fee schedule,,,24.11,,,fee schedule,,,,,,,,,10.5,,,fee schedule,,,,,,,,,173.0,,,per diem,,,21.83,,,fee schedule,,,54.75,,,percent of total billed charges,,,10.53,,,fee schedule,,,12.05,,,fee schedule,,,10.74,,,fee schedule,,,204.0,,,per diem,,,10.5,,,fee schedule,,,54.75,,,percent of total billed charges,,,12.05,,,fee schedule,,,10.74,,,fee schedule,,,,,,,,,62.05,,,percent of total billed charges,,,33.58,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,10.5,,,fee schedule,,,,,,,,,229.0,,,per diem,,,10.53,,,fee schedule,,,,,,,,,10.53,,,fee schedule,,,,,,,,
OT G0281 E-Stim Unattended for Wounds,10524826,CDM,0430,RC,G0281,HCPCS,16,EAPG,,,GO  ,outpatient,facility,,,73.00,21.90,73.0,873.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,742.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,73.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,73.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,520.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,572.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
OT L3764 Custom Dynamic E/W/H Splint,10524830,CDM,0274,RC,L3764,HCPCS,,,,,,inpatient,facility,,,804.00,241.20,311.95,683.40,,,,,,,,,,,,,,,,,,,,311.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,603.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,402.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.40,,,percent of total billed charges,,,361.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3764 Custom Dynamic E/W/H Splint,10524830,CDM,0274,RC,L3764,HCPCS,,,,,,outpatient,facility,,,804.00,241.20,341.70,1817.04,,,,,,,,791.14,,,fee schedule,,,,,,,,,405.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1664.28,,,fee schedule,,,559.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",806.96,,,fee schedule,,,1817.04,,,fee schedule,,,,,,,,,791.14,,,fee schedule,,,,,,,,,341.70,,,percent of total billed charges,,Paid in addition to outpatient services ,1640.16,,,fee schedule,,,603.0,,,percent of total billed charges,,,791.14,,,fee schedule,,,559.32,,,fee schedule,,,806.96,,,fee schedule,,,402.0,,,percent of total billed charges,,Paid in addition to outpatient services ,791.14,,,fee schedule,,,603.0,,,percent of total billed charges,,,559.32,,,fee schedule,,,806.96,,,fee schedule,,,,,,,,,683.40,,,percent of total billed charges,,,369.84,,,percent of total billed charges,,,,,,,,,,,,,,,791.14,,,fee schedule,,,,,,,,,,,,,,,791.14,,,fee schedule,,,,,,,,,791.14,,,fee schedule,,,,,,,,
OT L3702 Custom Static Elbow Splint,10524834,CDM,0274,RC,L3702,HCPCS,,,,,,inpatient,facility,,,313.00,93.90,121.44,266.05,,,,,,,,,,,,,,,,,,,,121.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,234.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.05,,,percent of total billed charges,,,140.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3702 Custom Static Elbow Splint,10524834,CDM,0274,RC,L3702,HCPCS,,,,,,outpatient,facility,,,313.00,93.90,133.03,707.38,,,,,,,,307.99,,,fee schedule,,,,,,,,,157.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,647.91,,,fee schedule,,,216.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",314.15,,,fee schedule,,,707.38,,,fee schedule,,,,,,,,,307.99,,,fee schedule,,,,,,,,,133.03,,,percent of total billed charges,,Paid in addition to outpatient services ,638.52,,,fee schedule,,,234.75,,,percent of total billed charges,,,307.99,,,fee schedule,,,216.38,,,fee schedule,,,314.15,,,fee schedule,,,156.5,,,percent of total billed charges,,Paid in addition to outpatient services ,307.99,,,fee schedule,,,234.75,,,percent of total billed charges,,,216.38,,,fee schedule,,,314.15,,,fee schedule,,,,,,,,,266.05,,,percent of total billed charges,,,143.98,,,percent of total billed charges,,,,,,,,,,,,,,,307.99,,,fee schedule,,,,,,,,,,,,,,,307.99,,,fee schedule,,,,,,,,,307.99,,,fee schedule,,,,,,,,
OT L3921 Custom Dynamic H/F Splint,10524836,CDM,0274,RC,L3921,HCPCS,,,,,,inpatient,facility,,,346.00,103.80,134.25,294.10,,,,,,,,,,,,,,,,,,,,134.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,259.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.10,,,percent of total billed charges,,,155.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3921 Custom Dynamic H/F Splint,10524836,CDM,0274,RC,L3921,HCPCS,,,,,,outpatient,facility,,,346.00,103.80,147.05,781.96,,,,,,,,340.46,,,fee schedule,,,,,,,,,174.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,716.22,,,fee schedule,,,240.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",347.27,,,fee schedule,,,781.96,,,fee schedule,,,,,,,,,340.46,,,fee schedule,,,,,,,,,147.05,,,percent of total billed charges,,Paid in addition to outpatient services ,705.84,,,fee schedule,,,259.5,,,percent of total billed charges,,,340.46,,,fee schedule,,,240.67,,,fee schedule,,,347.27,,,fee schedule,,,173.0,,,percent of total billed charges,,Paid in addition to outpatient services ,340.46,,,fee schedule,,,259.5,,,percent of total billed charges,,,240.67,,,fee schedule,,,347.27,,,fee schedule,,,,,,,,,294.10,,,percent of total billed charges,,,159.16,,,percent of total billed charges,,,,,,,,,,,,,,,340.46,,,fee schedule,,,,,,,,,,,,,,,340.46,,,fee schedule,,,,,,,,,340.46,,,fee schedule,,,,,,,,
OT L3933 Custom Static Finger Splint,10524840,CDM,0274,RC,L3933,HCPCS,,,,,,inpatient,facility,,,228.00,68.40,88.46,193.80,,,,,,,,,,,,,,,,,,,,88.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.80,,,percent of total billed charges,,,102.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3933 Custom Static Finger Splint,10524840,CDM,0274,RC,L3933,HCPCS,,,,,,outpatient,facility,,,228.00,68.40,96.90,515.28,,,,,,,,224.35,,,fee schedule,,,,,,,,,115.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,471.96,,,fee schedule,,,159.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",228.84,,,fee schedule,,,515.28,,,fee schedule,,,,,,,,,224.35,,,fee schedule,,,,,,,,,96.90,,,percent of total billed charges,,Paid in addition to outpatient services ,465.12,,,fee schedule,,,171.0,,,percent of total billed charges,,,224.35,,,fee schedule,,,159.88,,,fee schedule,,,228.84,,,fee schedule,,,114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,224.35,,,fee schedule,,,171.0,,,percent of total billed charges,,,159.88,,,fee schedule,,,228.84,,,fee schedule,,,,,,,,,193.80,,,percent of total billed charges,,,104.88,,,percent of total billed charges,,,,,,,,,,,,,,,224.35,,,fee schedule,,,,,,,,,,,,,,,224.35,,,fee schedule,,,,,,,,,224.35,,,fee schedule,,,,,,,,
OT L3905 Custom Dynamic W/H Splint,10524844,CDM,0274,RC,L3905,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3905 Custom Dynamic W/H Splint,10524844,CDM,0274,RC,L3905,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,2409.16,,,,,,,,1048.94,,,fee schedule,,,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,2206.62,,,fee schedule,,,743.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1069.92,,,fee schedule,,,2409.16,,,fee schedule,,,,,,,,,1048.94,,,fee schedule,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,2174.64,,,fee schedule,,,799.5,,,percent of total billed charges,,,1048.94,,,fee schedule,,,743.10,,,fee schedule,,,1069.92,,,fee schedule,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,1048.94,,,fee schedule,,,799.5,,,percent of total billed charges,,,743.10,,,fee schedule,,,1069.92,,,fee schedule,,,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,1048.94,,,fee schedule,,,,,,,,,,,,,,,1048.94,,,fee schedule,,,,,,,,,1048.94,,,fee schedule,,,,,,,,
OT L3913 Custom Static H/F Splint,10524848,CDM,0274,RC,L3913,HCPCS,,,,,,inpatient,facility,,,291.00,87.30,112.91,247.35,,,,,,,,,,,,,,,,,,,,112.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,218.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.35,,,percent of total billed charges,,,130.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3913 Custom Static H/F Splint,10524848,CDM,0274,RC,L3913,HCPCS,,,,,,outpatient,facility,,,291.00,87.30,123.68,657.66,,,,,,,,286.34,,,fee schedule,,,,,,,,,146.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,602.37,,,fee schedule,,,202.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",292.07,,,fee schedule,,,657.66,,,fee schedule,,,,,,,,,286.34,,,fee schedule,,,,,,,,,123.68,,,percent of total billed charges,,Paid in addition to outpatient services ,593.64,,,fee schedule,,,218.25,,,percent of total billed charges,,,286.34,,,fee schedule,,,202.94,,,fee schedule,,,292.07,,,fee schedule,,,145.5,,,percent of total billed charges,,Paid in addition to outpatient services ,286.34,,,fee schedule,,,218.25,,,percent of total billed charges,,,202.94,,,fee schedule,,,292.07,,,fee schedule,,,,,,,,,247.35,,,percent of total billed charges,,,133.86,,,percent of total billed charges,,,,,,,,,,,,,,,286.34,,,fee schedule,,,,,,,,,,,,,,,286.34,,,fee schedule,,,,,,,,,286.34,,,fee schedule,,,,,,,,
OT L3806 Custom Dynamic W/H/F Splint,10524852,CDM,0274,RC,L3806,HCPCS,,,,,,inpatient,facility,,,488.00,146.40,189.34,414.80,,,,,,,,,,,,,,,,,,,,189.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,366.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,244.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.80,,,percent of total billed charges,,,219.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3806 Custom Dynamic W/H/F Splint,10524852,CDM,0274,RC,L3806,HCPCS,,,,,,outpatient,facility,,,488.00,146.40,207.40,1102.88,,,,,,,,480.19,,,fee schedule,,,,,,,,,246.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1010.16,,,fee schedule,,,340.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",489.79,,,fee schedule,,,1102.88,,,fee schedule,,,,,,,,,480.19,,,fee schedule,,,,,,,,,207.40,,,percent of total billed charges,,Paid in addition to outpatient services ,995.52,,,fee schedule,,,366.0,,,percent of total billed charges,,,480.19,,,fee schedule,,,340.38,,,fee schedule,,,489.79,,,fee schedule,,,244.0,,,percent of total billed charges,,Paid in addition to outpatient services ,480.19,,,fee schedule,,,366.0,,,percent of total billed charges,,,340.38,,,fee schedule,,,489.79,,,fee schedule,,,,,,,,,414.80,,,percent of total billed charges,,,224.48,,,percent of total billed charges,,,,,,,,,,,,,,,480.19,,,fee schedule,,,,,,,,,,,,,,,480.19,,,fee schedule,,,,,,,,,480.19,,,fee schedule,,,,,,,,
OT L3919 Custom Static H Splint,10524856,CDM,0274,RC,L3919,HCPCS,,,,,,inpatient,facility,,,505.00,151.50,195.94,429.25,,,,,,,,,,,,,,,,,,,,195.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,378.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,252.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.25,,,percent of total billed charges,,,227.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3919 Custom Static H Splint,10524856,CDM,0274,RC,L3919,HCPCS,,,,,,outpatient,facility,,,505.00,151.50,202.94,667.90,,,,,,,,290.80,,,fee schedule,,,,,,,,,254.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,611.75,,,fee schedule,,,202.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",296.62,,,fee schedule,,,667.90,,,fee schedule,,,,,,,,,290.80,,,fee schedule,,,,,,,,,214.62,,,percent of total billed charges,,Paid in addition to outpatient services ,602.88,,,fee schedule,,,378.75,,,percent of total billed charges,,,290.80,,,fee schedule,,,202.94,,,fee schedule,,,296.62,,,fee schedule,,,252.5,,,percent of total billed charges,,Paid in addition to outpatient services ,290.80,,,fee schedule,,,378.75,,,percent of total billed charges,,,202.94,,,fee schedule,,,296.62,,,fee schedule,,,,,,,,,429.25,,,percent of total billed charges,,,232.30,,,percent of total billed charges,,,,,,,,,,,,,,,290.80,,,fee schedule,,,,,,,,,,,,,,,290.80,,,fee schedule,,,,,,,,,293.71,,,fee schedule,,,,,,,,
OT L3763 Custom Static E/W/H Splint,10524860,CDM,0274,RC,L3763,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3763 Custom Static E/W/H Splint,10524860,CDM,0274,RC,L3763,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,1731.16,,,,,,,,753.74,,,fee schedule,,,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1585.62,,,fee schedule,,,531.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",768.81,,,fee schedule,,,1731.16,,,fee schedule,,,,,,,,,753.74,,,fee schedule,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,1562.64,,,fee schedule,,,574.5,,,percent of total billed charges,,,753.74,,,fee schedule,,,531.97,,,fee schedule,,,768.81,,,fee schedule,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,753.74,,,fee schedule,,,574.5,,,percent of total billed charges,,,531.97,,,fee schedule,,,768.81,,,fee schedule,,,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,753.74,,,fee schedule,,,,,,,,,,,,,,,753.74,,,fee schedule,,,,,,,,,753.74,,,fee schedule,,,,,,,,
OT L3808 Custom Static W/H/F Splint,10524864,CDM,0274,RC,L3808,HCPCS,,,,,,inpatient,facility,,,369.00,110.70,143.17,313.65,,,,,,,,,,,,,,,,,,,,143.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,276.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,,166.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OT L3808 Custom Static W/H/F Splint,10524864,CDM,0274,RC,L3808,HCPCS,,,,,,outpatient,facility,,,369.00,110.70,156.82,833.94,,,,,,,,363.10,,,fee schedule,,,,,,,,,186.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,763.83,,,fee schedule,,,257.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",370.36,,,fee schedule,,,833.94,,,fee schedule,,,,,,,,,363.10,,,fee schedule,,,,,,,,,156.82,,,percent of total billed charges,,Paid in addition to outpatient services ,752.76,,,fee schedule,,,276.75,,,percent of total billed charges,,,363.10,,,fee schedule,,,257.46,,,fee schedule,,,370.36,,,fee schedule,,,184.5,,,percent of total billed charges,,Paid in addition to outpatient services ,363.10,,,fee schedule,,,276.75,,,percent of total billed charges,,,257.46,,,fee schedule,,,370.36,,,fee schedule,,,,,,,,,313.65,,,percent of total billed charges,,,169.74,,,percent of total billed charges,,,,,,,,,,,,,,,363.10,,,fee schedule,,,,,,,,,,,,,,,363.10,,,fee schedule,,,,,,,,,363.10,,,fee schedule,,,,,,,,
Rx Prescription Voice Prosthetic - Speech Therapis,10524910,CDM,0440,RC,92597,CPT,,,,,GN  ,outpatient,facility,,,450.00,135.00,66.76,382.5,,278.10,,,percent of total billed charges,,,66.84,,,fee schedule,,,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,140.62,,,fee schedule,,,90.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",68.10,,,fee schedule,,,153.34,,,fee schedule,,,,,,,,,66.76,,,fee schedule,,,,,,,,,173.0,,,per diem,,,138.58,,,fee schedule,,,337.5,,,percent of total billed charges,,,66.84,,,fee schedule,,,90.69,,,fee schedule,,,68.18,,,fee schedule,,,204.0,,,per diem,,,66.76,,,fee schedule,,,337.5,,,percent of total billed charges,,,90.69,,,fee schedule,,,68.18,,,fee schedule,,,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,66.76,,,fee schedule,,,,,,,,,229.0,,,per diem,,,66.84,,,fee schedule,,,,,,,,,66.84,,,fee schedule,,,,,,,,
Rx Prescription Voice Prosthetic - Speech Therapis,10524910,CDM,0440,RC,92597,CPT,272,EAPG,,,GN  ,outpatient,facility,,,450.00,135.00,175.46,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,198.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,175.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,193.01,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LENS ACRYSOF DIOPTER 13.0,10524913,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF DIOPTER 13.0,10524913,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS UV TORIC ASPHERIC 21.0D,10524914,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS UV TORIC ASPHERIC 21.0D,10524914,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARI CERV OZARK 4.5X12MM,10524920,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARI CERV OZARK 4.5X12MM,10524920,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 5X80MMX130CM,10524921,CDM,0278,RC,C2623,HCPCS,,,,,,inpatient,facility,,,4360.00,1308.00,1691.68,3706.0,,,,,,,,,,,,,,,,,,,,1691.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3706.0,,,percent of total billed charges,,,1962.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH IN.PACT 5X80MMX130CM,10524921,CDM,0278,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,,,,,,,,,,,,service not payable,,,,,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER TIB COMP STEMMED MD,10524922,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER TIB COMP STEMMED MD,10524922,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER FEM COMP STEMMED MD,10524923,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER FEM COMP STEMMED MD,10524923,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE CANN TIB 9X30MM,10524924,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE CANN TIB 9X30MM,10524924,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIXATION DEV TOGGLELOC ACL REC,10524925,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2294.00,688.20,890.07,1949.90,,,,,,,,,,,,,,,,,,,,890.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,974.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1720.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1949.90,,,percent of total billed charges,,,1032.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIXATION DEV TOGGLELOC ACL REC,10524925,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2294.00,688.20,974.95,1949.90,,,,,,,,,,,,,service not payable,,,,,,,1157.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,974.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1720.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1720.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1949.90,,,percent of total billed charges,,,1055.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LPS MOBILE E 4-6 10MM,10524927,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LPS MOBILE E 4-6 10MM,10524927,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING INSERT MLAP 10X71-75MM,10524928,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING INSERT MLAP 10X71-75MM,10524928,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 65 RT,10524929,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 65 RT,10524929,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS-FLEX GSF RT SZ E,10524930,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS-FLEX GSF RT SZ E,10524930,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 SZ3 9MM,10524936,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 SZ3 9MM,10524936,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PARIETAL TEMP LT,10524937,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,27319.00,8195.70,10599.77,23221.15,,13386.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11473.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10599.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11610.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20489.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13659.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23221.15,,,percent of total billed charges,,,12293.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PARIETAL TEMP LT,10524937,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,27319.00,8195.70,11473.98,23221.15,,13386.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11473.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13779.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11610.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20489.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13659.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20489.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,23221.15,,,percent of total billed charges,,,12566.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PARIETAL TEMP RT,10524938,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,22948.00,6884.40,8903.82,19505.80,,11244.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9638.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8903.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11474.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19505.80,,,percent of total billed charges,,,10326.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PARIETAL TEMP RT,10524938,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,22948.00,6884.40,9638.16,19505.80,,11244.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9638.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11574.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17211.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11474.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17211.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19505.80,,,percent of total billed charges,,,10556.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT BONE BONUS TRIAD 5CC,10524939,CDM,0278,RC,C9362,HCPCS,,,,,,inpatient,facility,,,5738.00,1721.40,2226.34,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2226.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4877.30,,,percent of total billed charges,,,2582.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT BONE BONUS TRIAD 5CC,10524939,CDM,0278,RC,C9362,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2409.96,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT BONE BONUS TRIAD 5CC,10524939,CDM,0278,RC,C9362,HCPCS,455,EAPG,,,,outpatient,facility,,,5738.00,1721.40,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE AL12 7F 90CM,10524940,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Aphasia Evaluation per hour - Speech Therapist Co,10525455,CDM,0444,RC,96105,CPT,,,,,GN  ,outpatient,facility,,,460.00,138.00,57.78,391.0,,284.28,,,percent of total billed charges,,,88.25,,,fee schedule,,,224.48,,,percent of total billed charges,,,232.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,185.64,,,fee schedule,,,57.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",89.86,,,fee schedule,,,202.34,,,fee schedule,,,,,,,,,88.10,,,fee schedule,,,,,,,,,173.0,,,per diem,,,182.95,,,fee schedule,,,345.0,,,percent of total billed charges,,,88.25,,,fee schedule,,,57.78,,,fee schedule,,,90.02,,,fee schedule,,,204.0,,,per diem,,,88.10,,,fee schedule,,,345.0,,,percent of total billed charges,,,57.78,,,fee schedule,,,90.02,,,fee schedule,,,,,,,,,391.0,,,percent of total billed charges,,,211.60,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,88.10,,,fee schedule,,,,,,,,,229.0,,,per diem,,,88.25,,,fee schedule,,,,,,,,,88.25,,,fee schedule,,,,,,,,
Aphasia Evaluation per hour - Speech Therapist Co,10525455,CDM,0444,RC,96105,CPT,310,EAPG,,,GN  ,outpatient,facility,,,460.00,138.00,212.38,338.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,288.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,212.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,212.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,293.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,322.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Standardized Cognitive Performance Testing per ho,10525456,CDM,0440,RC,96125,CPT,,,,,GN  ,outpatient,facility,,,449.00,134.70,74.26,381.65,,277.48,,,percent of total billed charges,,,93.49,,,fee schedule,,,219.11,,,percent of total billed charges,,,226.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,196.67,,,fee schedule,,,74.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.28,,,fee schedule,,,214.54,,,fee schedule,,,,,,,,,93.41,,,fee schedule,,,,,,,,,173.0,,,per diem,,,193.82,,,fee schedule,,,336.75,,,percent of total billed charges,,,93.49,,,fee schedule,,,74.26,,,fee schedule,,,95.36,,,fee schedule,,,204.0,,,per diem,,,93.41,,,fee schedule,,,336.75,,,percent of total billed charges,,,74.26,,,fee schedule,,,95.36,,,fee schedule,,,,,,,,,381.65,,,percent of total billed charges,,,206.54,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,93.41,,,fee schedule,,,,,,,,,229.0,,,per diem,,,93.49,,,fee schedule,,,,,,,,,93.49,,,fee schedule,,,,,,,,
Standardized Cognitive Performance Testing per ho,10525456,CDM,0440,RC,96125,CPT,310,EAPG,,,GN  ,outpatient,facility,,,449.00,134.70,212.38,338.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,288.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,212.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,212.38,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,293.26,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,322.59,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SPACER FEM STEMMED LARGE,10525502,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER FEM STEMMED LARGE,10525502,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 14.5,10525503,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 14.5,10525503,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TRAY TEMP SENSING 16F,10525504,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,348.00,104.40,147.90,295.80,,215.06,,,percent of total billed charges,,,,,,,,service not payable,169.82,,,percent of total billed charges,,,175.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,147.90,,,percent of total billed charges,,,,,,,,,261.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,174.0,,,percent of total billed charges,,,,,,,,service not payable,261.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,295.80,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,,,,,,,226.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,226.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LG HEX 7.3X70MM,10525508,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2028.00,608.40,786.86,1723.8,,,,,,,,,,,,,,,,,,,,786.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1723.8,,,percent of total billed charges,,,912.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LG HEX 7.3X70MM,10525508,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2028.00,608.40,861.90,1723.8,,,,,,,,,,,,,service not payable,,,,,,,1022.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1723.8,,,percent of total billed charges,,,932.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LG HEX 7.3X90MM,10525509,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2028.00,608.40,786.86,1723.8,,,,,,,,,,,,,,,,,,,,786.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1723.8,,,percent of total billed charges,,,912.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LG HEX 7.3X90MM,10525509,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2028.00,608.40,861.90,1723.8,,,,,,,,,,,,,service not payable,,,,,,,1022.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1723.8,,,percent of total billed charges,,,932.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4X50  X_71101050 X_SMITH NEPHEW,10525510,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,774.00,232.20,300.31,657.90,,,,,,,,,,,,,,,,,,,,300.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,657.90,,,percent of total billed charges,,,348.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4X50  X_71101050 X_SMITH NEPHEW,10525510,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,774.00,232.20,328.95,657.90,,,,,,,,,,,,,service not payable,,,,,,,390.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,328.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,580.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,387.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,580.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,657.90,,,percent of total billed charges,,,356.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT XACT CRTD 10X40MM TPR,10525511,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7213.00,2163.90,2798.64,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2798.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.05,,,percent of total billed charges,,,3245.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT XACT CRTD 10X40MM TPR,10525511,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7213.00,2163.90,3029.46,6131.05,,3534.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3029.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3638.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3065.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6131.05,,,percent of total billed charges,,,3317.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK RE 4.0X06MM,10528674,CDM,0272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO OFFSET 9X125MM,10528675,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO OFFSET 9X125MM,10528675,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 60MM LT,10528676,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 60MM LT,10528676,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING KNEE TIBIAL 63-67X14MM,10528678,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE TIBIAL 63-67X14MM,10528678,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING FEM HIP 22.2ID 36MM OD,10528679,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING FEM HIP 22.2ID 36MM OD,10528679,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ B 46MM,10528680,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11080.00,3324.00,4299.04,9418.0,,5429.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4653.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4299.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8310.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5540.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9418.0,,,percent of total billed charges,,,4986.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ B 46MM,10528680,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11080.00,3324.00,4653.60,9418.0,,5429.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4653.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5588.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4709.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8310.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5540.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8310.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9418.0,,,percent of total billed charges,,,5096.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER DUAL MOBILITY G7,10528681,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6295.00,1888.50,2442.46,5350.75,,3084.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2675.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5350.75,,,percent of total billed charges,,,2832.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER DUAL MOBILITY G7,10528681,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6295.00,1888.50,2643.90,5350.75,,3084.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3175.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2675.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5350.75,,,percent of total billed charges,,,2895.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT FT 5.5X40MM,10528685,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT FT 5.5X40MM,10528685,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT FT 5.5X35MM,10528686,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT FT 5.5X35MM,10528686,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NON-LK 3.5X14MM X_8150-37-014 X_ZIMMER,10528687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,331.00,99.30,128.43,281.35,,,,,,,,,,,,,,,,,,,,128.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,,148.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NON-LK 3.5X14MM X_8150-37-014 X_ZIMMER,10528687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,331.00,99.30,140.67,281.35,,,,,,,,,,,,,service not payable,,,,,,,166.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,248.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,,152.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NONLOCK 3.5X12MM,10528688,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,331.00,99.30,128.43,281.35,,,,,,,,,,,,,,,,,,,,128.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,,148.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NONLOCK 3.5X12MM,10528688,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,331.00,99.30,140.67,281.35,,,,,,,,,,,,,service not payable,,,,,,,166.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,248.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,,152.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NONLOCK 3.5X20MM,10528689,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,331.00,99.30,128.43,281.35,,,,,,,,,,,,,,,,,,,,128.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.35,,,percent of total billed charges,,,148.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NONLOCK 3.5X20MM,10528689,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,331.00,99.30,140.67,281.35,,,,,,,,,,,,,service not payable,,,,,,,166.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,248.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,248.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,281.35,,,percent of total billed charges,,,152.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TRANSFIXING 5X275MM BLACK,10528690,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TRANSFIXING 5X275MM BLACK,10528690,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR 24X85MM,10528691,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR 24X85MM,10528691,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW YUKON POLYAXIAL 3.5X16MM,10528693,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW YUKON POLYAXIAL 3.5X16MM,10528693,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW YUKON POLYAXIAL 3.5X18MM,10528694,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW YUKON POLYAXIAL 3.5X18MM,10528694,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR YUKON 3.5/4.0MM SIDE,10528695,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR YUKON 3.5/4.0MM SIDE,10528695,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE CASPIAN STR 3.5X80MM,10528696,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE CASPIAN STR 3.5X80MM,10528696,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 SZ4 14MM,10528697,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 SZ4 14MM,10528697,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X100MM,10528698,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X100MM,10528698,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM JRNY II COB LT 7,10528699,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM JRNY II COB LT 7,10528699,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT LEGION FEM LFT NRW SZ3,10528700,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6265.00,1879.50,2430.82,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2430.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5325.25,,,percent of total billed charges,,,2819.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT LEGION FEM LFT NRW SZ3,10528700,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6265.00,1879.50,2631.30,5325.25,,3069.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2631.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3160.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2662.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4698.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3132.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4698.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5325.25,,,percent of total billed charges,,,2881.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE 2.0CC ABS 2010 02,10528702,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE 2.0CC ABS 2010 02,10528702,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING HUMERUS 40MM PLUS 3,10528704,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING HUMERUS 40MM PLUS 3,10528704,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ANT CERV ST 4.5MM X16MM,10528714,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,930.00,279.00,360.84,790.5,,,,,,,,,,,,,,,,,,,,360.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ANT CERV ST 4.5MM X16MM,10528714,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,,,,,,,,,,,,service not payable,,,,,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ9 130D 165X43MM,10528716,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7377.00,2213.10,2862.28,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2862.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.45,,,percent of total billed charges,,,3319.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ9 130D 165X43MM,10528716,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3098.34,6270.45,,3614.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3098.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3688.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMX 20X5,10529796,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6869.00,2060.70,2665.17,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2665.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5838.65,,,percent of total billed charges,,,3091.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMX 20X5,10529796,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6869.00,2060.70,2884.98,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3464.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5838.65,,,percent of total billed charges,,,3159.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON CATH IN PACT X_IAV070004008P X_MEDTRONIC U,10529797,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4852.00,1455.60,2062.10,4124.20,,2998.54,,,percent of total billed charges,,,,,,,,service not payable,2367.78,,,percent of total billed charges,,,2447.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2062.10,,,percent of total billed charges,,,,,,,,,3639.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2426.0,,,percent of total billed charges,,,,,,,,service not payable,3639.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4124.20,,,percent of total billed charges,,,2231.92,,,percent of total billed charges,,,,,,,,,3153.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3153.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IMPACT 6MMX12MMX130CM,10529798,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4852.00,1455.60,2062.10,4124.20,,2998.54,,,percent of total billed charges,,,,,,,,service not payable,2367.78,,,percent of total billed charges,,,2447.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2062.10,,,percent of total billed charges,,,,,,,,,3639.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2426.0,,,percent of total billed charges,,,,,,,,service not payable,3639.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4124.20,,,percent of total billed charges,,,2231.92,,,percent of total billed charges,,,,,,,,,3153.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3153.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE RT 6-9 CD 12MM,10529799,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE RT 6-9 CD 12MM,10529799,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD RT SZ 7,10529800,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD RT SZ 7,10529800,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 520CC,10529801,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 520CC,10529801,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 640CC,10529802,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 640CC,10529802,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 685CC,10529803,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 685CC,10529803,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 755CC,10529804,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 755CC,10529804,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL CAN TFNA RT 125D 10X300,10529805,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10701.00,3210.30,4151.99,9095.85,,5243.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4151.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4547.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8025.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5350.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9095.85,,,percent of total billed charges,,,4815.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL CAN TFNA RT 125D 10X300,10529805,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10701.00,3210.30,4494.42,9095.85,,5243.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5397.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4547.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8025.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5350.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8025.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9095.85,,,percent of total billed charges,,,4922.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TFNA FENETRATED 75MM,10529806,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3309.00,992.70,1283.89,2812.65,,,,,,,,,,,,,,,,,,,,1283.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1406.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2481.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1654.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2812.65,,,percent of total billed charges,,,1489.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TFNA FENETRATED 75MM,10529806,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3309.00,992.70,1406.32,2812.65,,,,,,,,,,,,,service not payable,,,,,,,1669.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1406.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2481.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1654.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2481.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2812.65,,,percent of total billed charges,,,1522.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT HEAD HIP 49MM,10529807,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT HEAD HIP 49MM,10529807,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER DIST STEM SZ10,10529808,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER DIST STEM SZ10,10529808,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ALPS HUM PROX 90MM 4H LT,10529809,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4393.00,1317.90,1704.48,3734.05,,,,,,,,,,,,,,,,,,,,1704.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1867.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3294.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2196.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3734.05,,,percent of total billed charges,,,1976.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ALPS HUM PROX 90MM 4H LT,10529809,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4393.00,1317.90,1867.02,3734.05,,,,,,,,,,,,,service not payable,,,,,,,2215.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1867.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3294.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2196.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3294.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3734.05,,,percent of total billed charges,,,2020.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING ALPS 3.5X32MM,10529810,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING ALPS 3.5X32MM,10529810,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT LK TI ST 3.5X52MM NS,10529811,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT LK TI ST 3.5X52MM NS,10529811,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X250MM 130CM,10529812,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X300MM 130CM,10529813,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X250MM 130CM,10529814,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X300MM 130CM,10529815,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X250MM 130CM,10529816,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X300MM 130CM,10529817,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X250MM 130CM,10529818,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,860.87,,,percent of total billed charges,,,,,,,,service not payable,679.78,,,percent of total billed charges,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,905.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 3X150MM 135CM,10529819,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 3X200MM 135CM,10529820,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X40MM 135CM,10529821,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X60MM 135CM,10529822,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X80MM 135CM,10529823,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X100MM 135CM,10529824,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X120MM 135CM,10529825,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 4X150MM 135CM,10529826,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X20MM 135CM,10529827,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X40MM 135CM,10529828,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X60MM 135CM,10529829,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X80MM 135CM,10529830,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X100MM 135CM,10529831,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X120MM 135CM,10529832,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X150MM 135CM,10529833,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 5X200MM 135CM,10529834,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X20MM 80CM,10529835,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X20MM 135CM,10529836,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X40MM 80CM,10529837,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X40MM 135CM,10529838,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X60MM 135CM,10529839,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X80MM 135CM,10529840,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X100MM 135CM,10529841,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X120MM 135CM,10529842,CDM,0278,RC,C1725,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PTA 6X120MM 135CM,10529842,CDM,0278,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 6X150MM 135CM,10529843,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X20MM 80CM,10529844,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X20MM 135CM,10529845,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X40MM 80CM,10529846,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X40MM 135CM,10529847,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X60MM 135CM,10529848,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X80MM 135CM,10529849,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X120MM 135CM,10529850,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X150MM 135CM,10529851,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 7X200MM 135CM,10529852,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,490.07,,,percent of total billed charges,,,,,,,,service not payable,386.98,,,percent of total billed charges,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,515.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 8X20MM 80CM,10529853,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 8X20MM 135CM,10529854,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 8X40MM 80CM,10529855,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 8X40MM 135CM,10529856,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 8X60MM 135CM,10529857,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 8X80MM 135CM,10529858,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 9X20MM 80CM,10529859,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 9X20MM 135CM,10529860,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 9X40MM 80CM,10529861,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 9X40MM 135CM,10529862,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 9X60MM 135CM,10529863,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 9X80MM 135CM,10529864,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 10X20MM 80CM,10529865,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 10X20MM 135CM,10529866,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 10X40MM 80CM,10529867,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 10X40MM 135CM,10529868,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 10X60MM 135CM,10529869,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 12X40MM 80CM,10529870,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 12X40MM 135CM,10529871,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON PTA 12X60MM 135CM,10529872,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 30-40MMHG SZV BG,10529873,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,260.00,78.00,30.36,221.0,,160.68,,,percent of total billed charges,,,,,,,,service not payable,126.88,,,percent of total billed charges,,,131.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,110.5,,,percent of total billed charges,,,,,,,,,195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,130.0,,,percent of total billed charges,,,,,,,,service not payable,195.0,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,119.60,,,percent of total billed charges,,,,,,,,,169.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,169.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PEEK 20 100SQ CM,10529874,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,32840.00,9852.00,12741.92,27914.0,,16091.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13792.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12741.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13957.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24630.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16420.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27914.0,,,percent of total billed charges,,,14778.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PEEK 20 100SQ CM,10529874,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,32840.00,9852.00,13792.80,27914.0,,16091.6,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13792.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16564.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13957.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24630.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16420.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24630.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27914.0,,,percent of total billed charges,,,15106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CMF BONE STR 2.0H 1.6MM,10529875,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CMF BONE STR 2.0H 1.6MM,10529875,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT GLEN SHT PST 42MM 0,10529876,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT GLEN SHT PST 42MM 0,10529876,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST RAD TI STD LT 4H,10529882,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4246.00,1273.80,1647.45,3609.10,,,,,,,,,,,,,,,,,,,,1647.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1804.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3184.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2123.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3609.10,,,percent of total billed charges,,,1910.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST RAD TI STD LT 4H,10529882,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4246.00,1273.80,1804.55,3609.10,,,,,,,,,,,,,service not payable,,,,,,,2141.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1804.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3184.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2123.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3184.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3609.10,,,percent of total billed charges,,,1953.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NR CORTEX VA TI 2.4X14MM,10529883,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NR CORTEX VA TI 2.4X14MM,10529883,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 8X20,10530641,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 8X20,10530641,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 8X120,10530642,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4043.00,1212.90,1568.68,3436.55,,,,,,,,,,,,,,,,,,,,1568.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.55,,,percent of total billed charges,,,1819.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 8X120,10530642,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4043.00,1212.90,1718.27,3436.55,,,,,,,,,,,,,service not payable,,,,,,,2039.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3436.55,,,percent of total billed charges,,,1859.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PERIP120CM CATH5FR 8X150,10530643,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,3360.00,1008.00,1303.68,2856.0,,,,,,,,,,,,,,,,,,,,1303.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1428.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2520.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1680.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2856.0,,,percent of total billed charges,,,1512.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PERIP120CM CATH5FR 8X150,10530643,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,3360.00,1008.00,1428.0,2856.0,,,,,,,,,,,,,service not payable,,,,,,,1694.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1428.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2520.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1680.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2520.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2856.0,,,percent of total billed charges,,,1545.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DCB 4X40MM 130CM,10530644,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DCB 4X120MM 130CM,10530645,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4852.00,1455.60,2062.10,4124.20,,2998.54,,,percent of total billed charges,,,,,,,,service not payable,2367.78,,,percent of total billed charges,,,2447.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2062.10,,,percent of total billed charges,,,,,,,,,3639.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2426.0,,,percent of total billed charges,,,,,,,,service not payable,3639.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4124.20,,,percent of total billed charges,,,2231.92,,,percent of total billed charges,,,,,,,,,3153.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3153.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 5F 4X40MMX80CM,10530646,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 5F 4X60MMX80CM,10530647,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 5F 4X120MMX80CM,10530648,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 5X40MMX80CM,10530649,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 5X60MMX80CM,10530650,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 5X80MMX80CM,10530651,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 5X120MMX80CM,10530652,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 6X40MMX80CM,10530653,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 6X60MMX80CM,10530654,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 6X80MMX80CM,10530655,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 6F 6X120MMX80CM,10530656,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 7X40MMX80CM,10530657,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 7X60MMX80CM,10530658,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 7X80MMX80CM,10530659,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 8X40MMX80CM,10530660,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 8X40MMX130CM,10530661,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 8X60MMX80CM,10530662,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 8X60MMX130CM,10530663,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 8X80MMX130CM,10530664,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 9X40MMX80CM,10530665,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 9X40MMX130CM,10530666,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 9X60MMX80CM,10530667,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 9X60MMX130CM,10530668,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 9X80MMX80CM,10530669,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 9X80MMX130CM,10530670,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 10X40MMX80CM,10530671,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 7F 10X40MMX130CM,10530672,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 9F 12X40MMX80CM,10530673,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH IN.PACT 9F 12X40MMX130CM,10530674,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2578.05,5156.10,,3748.79,,,percent of total billed charges,,,,,,,,service not payable,2960.21,,,percent of total billed charges,,,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3942.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 1.5X20MMX150CM,10530675,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 1.5X40MMX150CM,10530676,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.0X20MMX150CM,10530677,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.0X40MMX150CM,10530678,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.0X60MMX150CM,10530679,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.0X80MMX150CM,10530680,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 2.0X100MMX150CM,10530681,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 2.0X120MMX150CM,10530682,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 2.0X150MMX150CM,10530683,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.5X20MMX150CM,10530684,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.5X40MMX150CM,10530685,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.5X60MMX150CM,10530686,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 2.5X80MMX150CM,10530687,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 2.5X100MMX150CM,10530688,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 2.5X120MMX150CM,10530689,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 2.5X150MMX150CM,10530690,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.0X20MMX150CM,10530691,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.0X40MMX150CM,10530692,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.0X60MMX150CM,10530693,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.0X100MMX150CM,10530694,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.0X120MMX150CM,10530695,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.0X150MMX150CM,10530696,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.5X20MMX150CM,10530697,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.5X40MMX150CM,10530698,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.5X60MMX150CM,10530699,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 3.5X80MMX150CM,10530700,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.5X100MMX150CM,10530701,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.5X120MMX150CM,10530702,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.5X150MMX150CM,10530703,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 3.5X210MMX150CM,10530704,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 4.0X20MMX150CM,10530705,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 4.0X60MMX150CM,10530706,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F 0.014IN 4.0X80MMX150CM,10530707,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 4.0X100MMX150CM,10530708,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 4.0X120MMX150CM,10530709,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.83,1231.65,,895.48,,,percent of total billed charges,,,,,,,,service not payable,707.11,,,percent of total billed charges,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.83,,,percent of total billed charges,,,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,941.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 4F .014IN 4.0X150MMX150CM,10530710,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 5F .014IN 5.0X150MMX150CM,10530711,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 5F .014IN 5.0X200MMX150CM,10530712,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 5F .014IN 6.0X150MMX150CM,10530713,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH 6F .014IN 6.0X200MMX150CM,10530714,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,928.24,,,percent of total billed charges,,,,,,,,service not payable,732.98,,,percent of total billed charges,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,976.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Remove transvenous pacemaker electrode single lead,10531022,CDM,0481,RC,33234,CPT,,,,,,outpatient,facility,,,5128.00,1538.40,2358.88,6509.0,,5128.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,2586.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,3846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,3846.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4358.80,,,percent of total billed charges,,,2358.88,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Remove transvenous pacemaker electrode single lead,10531022,CDM,0481,RC,33234,CPT,05221,APC,,,,outpatient,facility,,,5128.00,1538.40,3347.52,8015.59,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7341.71,,,fee schedule,,,3347.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3559.77,,,fee schedule,,,8015.59,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,7235.31,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,3347.52,,,fee schedule,,,3559.77,,,fee schedule,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3347.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3559.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,,,,,,,3489.97,,,fee schedule,,,,,,,,,3524.73,,,fee schedule,,,,,,,,
Remove transvenous pacemaker electrode single lead,10531022,CDM,0481,RC,33234,CPT,74,EAPG,,,,outpatient,facility,,,5128.00,1538.40,1489.86,2281.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1928.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1639.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2281.97,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1489.86,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1638.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
EGD flex Transoral w/Transendoscopic US Guide Int,10531038,CDM,0361,RC,43238,CPT,,,,,,outpatient,facility,,,3143.00,942.90,1445.78,3666.78,,3143.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,1585.33,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,2357.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,2357.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2671.55,,,percent of total billed charges,,,1445.78,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
EGD flex Transoral w/Transendoscopic US Guide Int,10531038,CDM,0361,RC,43238,CPT,05302,APC,,,,outpatient,facility,,,3143.00,942.90,1744.90,4178.13,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,3826.87,,,fee schedule,,,1744.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1855.53,,,fee schedule,,,4178.13,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,3771.41,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,1744.90,,,fee schedule,,,1855.53,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,1744.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1855.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,1837.27,,,fee schedule,,,,,,,,
EGD flex Transoral w/Transendoscopic US Guide Int,10531038,CDM,0361,RC,43238,CPT,134,EAPG,,,,outpatient,facility,,,3143.00,942.90,1403.14,4560.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4560.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3876.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1403.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1403.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1403.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1917.04,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2108.74,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH DXTERITY TRA UL40 SHA 5F,10531115,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,506.76,,,percent of total billed charges,,,,,,,,service not payable,400.16,,,percent of total billed charges,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,533.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert/replace permanent pacemaker w/ventric elect,10531136,CDM,0481,RC,33207,CPT,,,,,,outpatient,facility,,,17000.00,5100.00,7820.0,18583.0,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,8574.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,12750.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,12750.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14450.0,,,percent of total billed charges,,,7820.0,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert/replace permanent pacemaker w/ventric elect,10531136,CDM,0481,RC,33207,CPT,05223,APC,,,,outpatient,facility,,,17000.00,5100.00,9626.29,23049.94,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,21112.12,,,fee schedule,,,9626.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10229.20,,,fee schedule,,,23049.94,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,20806.14,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,9626.29,,,fee schedule,,,10229.20,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,9626.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",10229.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,10128.58,,,fee schedule,,,,,,,,
Insert/replace permanent pacemaker w/ventric elect,10531136,CDM,0481,RC,33207,CPT,86,EAPG,,,,outpatient,facility,,,17000.00,5100.00,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COMP FEM CMNTLESS SZ7 RT,10531144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CMNTLESS SZ7 RT,10531144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB AOX RP ATTUNE SZ6,10531145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB AOX RP ATTUNE SZ6,10531145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA3 8.5X55MM,10531146,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA3 8.5X55MM,10531146,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA3 9.5X55MM,10531147,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA3 9.5X55MM,10531147,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMX 20X15,10531149,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6869.00,2060.70,2665.17,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2665.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5838.65,,,percent of total billed charges,,,3091.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMX 20X15,10531149,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6869.00,2060.70,2884.98,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3464.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5838.65,,,percent of total billed charges,,,3159.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMX 20X20,10531150,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6869.00,2060.70,2665.17,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2665.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5838.65,,,percent of total billed charges,,,3091.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMX 20X20,10531150,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6869.00,2060.70,2884.98,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3464.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5838.65,,,percent of total billed charges,,,3159.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL CANN 11MM LT,10531151,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9530.00,2859.00,3697.64,8100.5,,4669.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4002.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3697.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4050.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7147.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8100.5,,,percent of total billed charges,,,4288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL CANN 11MM LT,10531151,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9530.00,2859.00,4002.60,8100.5,,4669.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4002.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4806.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4050.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4765.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8100.5,,,percent of total billed charges,,,4383.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL CANN 10MM LT,10531152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9530.00,2859.00,3697.64,8100.5,,4669.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4002.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3697.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4050.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7147.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8100.5,,,percent of total billed charges,,,4288.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL CANN 10MM LT,10531152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9530.00,2859.00,4002.60,8100.5,,4669.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4002.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4806.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4050.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4765.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8100.5,,,percent of total billed charges,,,4383.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK 5X52MM STRL,10531153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1788.00,536.40,693.74,1519.8,,,,,,,,,,,,,,,,,,,,693.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,759.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1341.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,894.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.8,,,percent of total billed charges,,,804.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK 5X52MM STRL,10531153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1788.00,536.40,759.90,1519.8,,,,,,,,,,,,,service not payable,,,,,,,901.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,759.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1341.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,894.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1341.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1519.8,,,percent of total billed charges,,,822.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFN CANN RT 130D 420X14MM,10531154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFN CANN RT 130D 420X14MM,10531154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NAIL FEM 10.5X120MM,10531155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NAIL FEM 10.5X120MM,10531155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK 5X58MM STRL,10531156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1784.00,535.20,692.19,1516.40,,,,,,,,,,,,,,,,,,,,692.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1516.40,,,percent of total billed charges,,,802.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK 5X58MM STRL,10531156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1784.00,535.20,758.20,1516.40,,,,,,,,,,,,,service not payable,,,,,,,899.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,758.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,892.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1338.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1516.40,,,percent of total billed charges,,,820.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANC TI 3.5 X 18MM,10531160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANC TI 3.5 X 18MM,10531160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 4X52MM,10531161,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,776.00,232.80,301.09,659.60,,,,,,,,,,,,,,,,,,,,301.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,329.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,388.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.60,,,percent of total billed charges,,,349.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 4X52MM,10531161,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,776.00,232.80,329.80,659.60,,,,,,,,,,,,,service not payable,,,,,,,391.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,329.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,582.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,388.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,582.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,659.60,,,percent of total billed charges,,,356.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM SHOULDER COMP 5MM,10531162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM SHOULDER COMP 5MM,10531162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FLUTED TIB MOBILE MD SZ 6,10531163,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FLUTED TIB MOBILE MD SZ 6,10531163,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LPS MOBILE G 6-8 10MM,10531164,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LPS MOBILE G 6-8 10MM,10531164,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LPS FLEX RT SZ G,10531165,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LPS FLEX RT SZ G,10531165,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FLUTED TIB MOBILE SZ 7,10531166,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FLUTED TIB MOBILE SZ 7,10531166,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 12.5D,10531168,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 12.5D,10531168,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LOW PROF 3.5X30MM,10531169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LOW PROF 3.5X30MM,10531169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC LOCKING 2.7X18MM,10531170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC LOCKING 2.7X18MM,10531170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LOCKING 3.5X16MM,10531171,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,571.00,171.30,221.55,485.35,,,,,,,,,,,,,,,,,,,,221.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,428.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,285.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.35,,,percent of total billed charges,,,256.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LOCKING 3.5X16MM,10531171,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,571.00,171.30,242.67,485.35,,,,,,,,,,,,,service not payable,,,,,,,288.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,242.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,428.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,285.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,428.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,485.35,,,percent of total billed charges,,,262.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING INSERT 14X63-67MM,10531172,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING INSERT 14X63-67MM,10531172,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING INSERT 12X63-67MM,10531173,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING INSERT 12X63-67MM,10531173,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN MAX BT 1.4MM X 5 IN,10531175,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,157.00,47.10,66.72,133.45,,97.03,,,percent of total billed charges,,,,,,,,service not payable,76.62,,,percent of total billed charges,,,79.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,66.72,,,percent of total billed charges,,,,,,,,,117.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,78.5,,,percent of total billed charges,,,,,,,,service not payable,117.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,133.45,,,percent of total billed charges,,,72.22,,,percent of total billed charges,,,,,,,,,102.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,102.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER STAPLE SURG FUSEFORCE,10531176,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1268.00,380.40,491.98,1077.8,,,,,,,,,,,,,,,,,,,,491.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,951.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,634.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,,570.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER STAPLE SURG FUSEFORCE,10531176,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1268.00,380.40,538.90,1077.8,,,,,,,,,,,,,service not payable,,,,,,,639.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,538.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,951.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,634.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,951.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,,583.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADED 4.0X25MM,10531177,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1945.00,583.50,754.66,1653.25,,,,,,,,,,,,,,,,,,,,754.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,972.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,875.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADED 4.0X25MM,10531177,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1945.00,583.50,826.62,1653.25,,,,,,,,,,,,,service not payable,,,,,,,981.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,826.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,972.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COUNTERSINK GOLD 4MM,10531178,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1606.00,481.80,623.13,1365.10,,,,,,,,,,,,,,,,,,,,623.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.10,,,percent of total billed charges,,,722.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COUNTERSINK GOLD 4MM,10531178,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1606.00,481.80,682.55,1365.10,,,,,,,,,,,,,service not payable,,,,,,,810.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1365.10,,,percent of total billed charges,,,738.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER 5F SELECT,10531180,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,422.09,,,percent of total billed charges,,,,,,,,service not payable,333.30,,,percent of total billed charges,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,443.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 50MM,10537056,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,31570.00,9471.00,12249.16,26834.5,,15469.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13259.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12249.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13417.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23677.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15785.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26834.5,,,percent of total billed charges,,,14206.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 50MM,10537056,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,31570.00,9471.00,13259.4,26834.5,,15469.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13259.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15923.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13417.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23677.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15785.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23677.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26834.5,,,percent of total billed charges,,,14522.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR HIP 56MM,10537057,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,42716.00,12814.80,16573.81,36308.60,,20930.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17940.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16573.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18154.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,32037.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36308.60,,,percent of total billed charges,,,19222.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR HIP 56MM,10537057,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,42716.00,12814.80,17940.72,36308.60,,20930.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17940.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21545.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18154.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,32037.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,32037.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,36308.60,,,percent of total billed charges,,,19649.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE MICRO ACUTRAK2 30MM,10537062,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2448.00,734.40,949.82,2080.80,,,,,,,,,,,,,,,,,,,,949.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2080.80,,,percent of total billed charges,,,1101.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE MICRO ACUTRAK2 30MM,10537062,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2448.00,734.40,1040.40,2080.80,,,,,,,,,,,,,service not payable,,,,,,,1234.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2080.80,,,percent of total billed charges,,,1126.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DIAG JL4 4F 100CM,10537063,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,43.26,,,percent of total billed charges,,,,,,,,service not payable,34.16,,,percent of total billed charges,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER DIAG JR40 4F 100CM,10537064,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,43.26,,,percent of total billed charges,,,,,,,,service not payable,34.16,,,percent of total billed charges,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,45.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 3H 52MM SZ E,10537065,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 3H 52MM SZ E,10537065,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB G7 SZ E 42MM,10537066,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6295.00,1888.50,2442.46,5350.75,,3084.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2643.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2442.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2675.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5350.75,,,percent of total billed charges,,,2832.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB G7 SZ E 42MM,10537066,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6295.00,1888.50,2643.90,5350.75,,3084.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2643.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3175.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2675.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5350.75,,,percent of total billed charges,,,2895.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ARCOS REV 14X150MM,10537067,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10885.00,3265.50,4223.38,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4223.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9252.25,,,percent of total billed charges,,,4898.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ARCOS REV 14X150MM,10537067,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10885.00,3265.50,4571.70,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5490.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9252.25,,,percent of total billed charges,,,5007.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD CERAMIC 28MM,10537068,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7311.00,2193.30,2836.67,6214.35,,3582.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3070.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2836.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3107.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6214.35,,,percent of total billed charges,,,3289.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD CERAMIC 28MM,10537068,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7311.00,2193.30,3070.62,6214.35,,3582.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3070.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3687.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3107.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6214.35,,,percent of total billed charges,,,3363.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING VIVACIT-E DM 28X42MM,10537069,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING VIVACIT-E DM 28X42MM,10537069,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
READYWRAP CALF LENGTH 30IN,10537071,CDM,0272,RC,A6451,HCPCS,,,,,,outpatient,facility,,,1399.00,419.70,594.58,1189.15,,864.58,,,percent of total billed charges,,,,,,,,service not payable,682.71,,,percent of total billed charges,,,705.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,594.58,,,percent of total billed charges,,,,,,,,,1049.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,699.5,,,percent of total billed charges,,,,,,,,service not payable,1049.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1189.15,,,percent of total billed charges,,,643.54,,,percent of total billed charges,,,,,,,,,909.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,909.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE RELINE TI 5.5X55MM,10537072,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE RELINE TI 5.5X55MM,10537072,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER BI -MENTUM PE 28/53,10537077,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER BI -MENTUM PE 28/53,10537077,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP PRESSFIT BI-MENTUM 53MM,10537078,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP PRESSFIT BI-MENTUM 53MM,10537078,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WRAP READY XL AVERAGE,10537079,CDM,0272,RC,A6451,HCPCS,,,,,,outpatient,facility,,,1399.00,419.70,594.58,1189.15,,864.58,,,percent of total billed charges,,,,,,,,service not payable,682.71,,,percent of total billed charges,,,705.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,594.58,,,percent of total billed charges,,,,,,,,,1049.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,699.5,,,percent of total billed charges,,,,,,,,service not payable,1049.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1189.15,,,percent of total billed charges,,,643.54,,,percent of total billed charges,,,,,,,,,909.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,909.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULR LT SZ 1-2 11MM,10537080,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULR LT SZ 1-2 11MM,10537080,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE TIB NP JRNY SZ1 LT,10537081,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3427.00,1028.10,1329.68,2912.95,,,,,,,,,,,,,,,,,,,,1329.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.95,,,percent of total billed charges,,,1542.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE TIB NP JRNY SZ1 LT,10537081,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3427.00,1028.10,1456.47,2912.95,,,,,,,,,,,,,service not payable,,,,,,,1728.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.95,,,percent of total billed charges,,,1576.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ANKL INFIN POLY SZ3 6MM,10537082,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ANKL INFIN POLY SZ3 6MM,10537082,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB T2 STD 13X330MM,10537083,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4085.00,1225.50,1584.98,3472.25,,,,,,,,,,,,,,,,,,,,1584.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1736.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3063.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2042.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3472.25,,,percent of total billed charges,,,1838.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB T2 STD 13X330MM,10537083,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4085.00,1225.50,1736.12,3472.25,,,,,,,,,,,,,service not payable,,,,,,,2060.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1736.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3063.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2042.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3063.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3472.25,,,percent of total billed charges,,,1879.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE XTEND ECC 424MM,10537084,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE XTEND ECC 424MM,10537084,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CEMENTED TPRD 14X30MM,10537085,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CEMENTED TPRD 14X30MM,10537085,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIBIA PSN 5 DEG SZER,10537086,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIBIA PSN 5 DEG SZER,10537086,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING PSN 13MM SZ6-9,10537087,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING PSN 13MM SZ6-9,10537087,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULR RT SZ 3-4 11MM,10537089,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULR RT SZ 3-4 11MM,10537089,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OCCLUDER DELIV SYS 8F 45D 80CM,10537090,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER DELIV SYS 8F 45D 80CM,10537090,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS DELIV OCCLUDER 9F 45D 80CM,10537091,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS DELIV OCCLUDER 9F 45D 80CM,10537091,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 12X80MM 120CM,10537383,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 12X80MM 120CM,10537383,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CEMENTLESS RT SZ5,10537385,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CEMENTLESS RT SZ5,10537385,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE TIBI SZ 5,10537386,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE TIBI SZ 5,10537386,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MP ST T8STRDRV 2.7X40MM,10537387,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MP ST T8STRDRV 2.7X40MM,10537387,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MP ST T8STRDRV 2.7X44MM,10537388,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MP ST T8STRDRV 2.7X44MM,10537388,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MP ST T8STRDRV 2.7X46MM,10537389,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MP ST T8STRDRV 2.7X46MM,10537389,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST T8STRDRV 2.7X38MM,10537390,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST T8STRDRV 2.7X38MM,10537390,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 2.7-3.5X112MM 6H,10537391,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7474.00,2242.20,2899.91,6352.90,,3662.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3139.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2899.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3176.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6352.90,,,percent of total billed charges,,,3363.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 2.7-3.5X112MM 6H,10537391,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7474.00,2242.20,3139.08,6352.90,,3662.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3139.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3769.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3176.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6352.90,,,percent of total billed charges,,,3438.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP 2.7-3.5X112MM 6H,10537392,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7474.00,2242.20,2899.91,6352.90,,3662.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3139.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2899.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3176.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6352.90,,,percent of total billed charges,,,3363.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP 2.7-3.5X112MM 6H,10537392,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7474.00,2242.20,3139.08,6352.90,,3662.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3139.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3769.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3176.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6352.90,,,percent of total billed charges,,,3438.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST T8STRDRV 2.7X42MM,10537393,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST T8STRDRV 2.7X42MM,10537393,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST T8STRDRV 2.7X40MM,10537394,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST T8STRDRV 2.7X40MM,10537394,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SS ST LK T8 S-DRV 2.7X42,10537395,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SS ST LK T8 S-DRV 2.7X42,10537395,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW ST T8STRDRV 2.7X44MM,10537396,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW ST T8STRDRV 2.7X44MM,10537396,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T8 STARDRV 2.7X34MM,10537397,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,305.00,91.50,118.34,259.25,,,,,,,,,,,,,,,,,,,,118.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.25,,,percent of total billed charges,,,137.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T8 STARDRV 2.7X34MM,10537397,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,305.00,91.50,129.62,259.25,,,,,,,,,,,,,service not payable,,,,,,,153.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,228.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,259.25,,,percent of total billed charges,,,140.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T8 STARDRV 2.7X40MM,10537398,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,305.00,91.50,118.34,259.25,,,,,,,,,,,,,,,,,,,,118.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.25,,,percent of total billed charges,,,137.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T8 STARDRV 2.7X40MM,10537398,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,305.00,91.50,129.62,259.25,,,,,,,,,,,,,service not payable,,,,,,,153.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,228.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,259.25,,,percent of total billed charges,,,140.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T8 STARDRV 2.7X46MM,10537399,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,305.00,91.50,118.34,259.25,,,,,,,,,,,,,,,,,,,,118.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.25,,,percent of total billed charges,,,137.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T8 STARDRV 2.7X46MM,10537399,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,305.00,91.50,129.62,259.25,,,,,,,,,,,,,service not payable,,,,,,,153.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,228.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,259.25,,,percent of total billed charges,,,140.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SDST LNG THREAD 4.0X40MM,10537402,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1945.00,583.50,754.66,1653.25,,,,,,,,,,,,,,,,,,,,754.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,972.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1653.25,,,percent of total billed charges,,,875.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SDST LNG THREAD 4.0X40MM,10537402,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1945.00,583.50,826.62,1653.25,,,,,,,,,,,,,service not payable,,,,,,,981.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,826.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1458.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,972.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1458.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1653.25,,,percent of total billed charges,,,894.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE MEDIAL SZ C RT,10537404,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE MEDIAL SZ C RT,10537404,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB MEDI RT SZ C 10MM,10537406,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB MEDI RT SZ C 10MM,10537406,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB RT MEDIAL SZ 12,10537407,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB RT MEDIAL SZ 12,10537407,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NUCLEUS PROFILE CONTOUR CI612,10537408,CDM,0278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,42250.00,12675.00,16393.0,35912.5,,20702.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17745.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,16393.0,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17956.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,31687.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21125.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35912.5,,,percent of total billed charges,,,19012.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NUCLEUS PROFILE CONTOUR CI612,10537408,CDM,0278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,42250.00,12675.00,17745.0,35912.5,,20702.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17745.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,21310.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17956.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,31687.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,21125.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,31687.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,35912.5,,,percent of total billed charges,,,19435.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT WRIST THMB BK RT MD 8IN,10537409,CDM,0274,RC,L3908,HCPCS,,,,,,inpatient,facility,,,51.00,15.30,19.79,43.35,,,,,,,,,,,,,,,,,,,,19.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.35,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPLINT WRIST THMB BK RT MD 8IN,10537409,CDM,0274,RC,L3908,HCPCS,,,,,,outpatient,facility,,,51.00,15.30,21.68,115.26,,,,,,,,50.18,,,fee schedule,,,,,,,,,25.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,105.57,,,fee schedule,,,46.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",51.18,,,fee schedule,,,115.26,,,fee schedule,,,,,,,,,50.18,,,fee schedule,,,,,,,,,21.68,,,percent of total billed charges,,Paid in addition to outpatient services ,104.04,,,fee schedule,,,38.25,,,percent of total billed charges,,,50.18,,,fee schedule,,,46.09,,,fee schedule,,,51.18,,,fee schedule,,,25.5,,,percent of total billed charges,,Paid in addition to outpatient services ,50.18,,,fee schedule,,,38.25,,,percent of total billed charges,,,46.09,,,fee schedule,,,51.18,,,fee schedule,,,,,,,,,43.35,,,percent of total billed charges,,,23.46,,,percent of total billed charges,,,,,,,,,,,,,,,50.18,,,fee schedule,,,,,,,,,,,,,,,50.18,,,fee schedule,,,,,,,,,50.18,,,fee schedule,,,,,,,,
COMP TIBIAL SZ 6 50X77MM,10538529,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16581.00,4974.30,6433.43,14093.85,,8124.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6964.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6433.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7046.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12435.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8290.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14093.85,,,percent of total billed charges,,,7461.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIAL SZ 6 50X77MM,10538529,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16581.00,4974.30,6964.02,14093.85,,8124.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6964.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8363.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7046.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12435.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8290.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12435.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14093.85,,,percent of total billed charges,,,7627.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM FLUTED STR 14X190MM,10538530,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15814.00,4744.20,6135.83,13441.9,,7748.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6641.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6135.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6720.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11860.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7907.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13441.9,,,percent of total billed charges,,,7116.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM FLUTED STR 14X190MM,10538530,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15814.00,4744.20,6641.88,13441.9,,7748.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6641.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7976.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6720.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11860.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7907.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11860.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13441.9,,,percent of total billed charges,,,7274.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM XT DIST RT SZ B,10538531,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21913.00,6573.90,8502.24,18626.05,,10737.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9203.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8502.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9313.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18626.05,,,percent of total billed charges,,,9860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM XT DIST RT SZ B,10538531,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21913.00,6573.90,9203.46,18626.05,,10737.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9203.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11052.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9313.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18626.05,,,percent of total billed charges,,,10079.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT FEM XT POLY BOX SZ B,10538532,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2196.00,658.80,852.05,1866.60,,,,,,,,,,,,,,,,,,,,852.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,933.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1647.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1866.60,,,percent of total billed charges,,,988.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT FEM XT POLY BOX SZ B,10538532,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2196.00,658.80,933.30,1866.60,,,,,,,,,,,,,service not payable,,,,,,,1107.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,933.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1647.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1647.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1866.60,,,percent of total billed charges,,,1010.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP SEGMENTAL SZ B 14MM,10538533,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7986.00,2395.80,3098.57,6788.10,,3913.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3354.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3098.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3394.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5989.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3993.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6788.10,,,percent of total billed charges,,,3593.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP SEGMENTAL SZ B 14MM,10538533,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7986.00,2395.80,3354.12,6788.10,,3913.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3354.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4028.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3394.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5989.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3993.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5989.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6788.10,,,percent of total billed charges,,,3673.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COLLAR STEM 9-16X35MM,10538534,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10398.00,3119.40,4034.42,8838.30,,5095.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4367.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4034.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4419.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7798.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5199.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8838.30,,,percent of total billed charges,,,4679.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAR STEM 9-16X35MM,10538534,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10398.00,3119.40,4367.16,8838.30,,5095.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4367.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5244.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4419.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7798.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5199.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7798.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8838.30,,,percent of total billed charges,,,4783.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PENILE PCON 700MS 16CM,10538535,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,31812.00,9543.60,12343.06,27040.20,,15587.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13361.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12343.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13520.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23859.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15906.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27040.20,,,percent of total billed charges,,,14315.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PENILE PCON 700MS 16CM,10538535,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,31812.00,9543.60,13361.04,27040.20,,15587.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13361.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16045.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13520.1,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23859.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15906.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23859.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27040.20,,,percent of total billed charges,,,14633.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX 4.5X44MM,10538536,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX 4.5X44MM,10538536,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT H-TIB TI 4.5X40MM,10538537,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT H-TIB TI 4.5X40MM,10538537,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CONTOURLOCK HTO LT 71MM,10538538,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CONTOURLOCK HTO LT 71MM,10538538,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K WIRE 1.6MM X 15CM,10538539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K WIRE 1.6MM X 15CM,10538539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANK FUS SHRT ANT 3H,10538547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6803.00,2040.90,2639.56,5782.55,,3333.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2857.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2639.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2891.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5102.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3401.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5782.55,,,percent of total billed charges,,,3061.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANK FUS SHRT ANT 3H,10538547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6803.00,2040.90,2857.26,5782.55,,3333.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2857.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3431.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2891.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5102.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3401.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5102.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5782.55,,,percent of total billed charges,,,3129.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CEM AS VEGA SZ5 L,10538550,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CEM AS VEGA SZ5 L,10538550,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATEAU TIBIA SZ T4 80X55MM,10538551,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATEAU TIBIA SZ T4 80X55MM,10538551,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSRT GLIDE SURFACE T4/T4 12MM,10538552,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSRT GLIDE SURFACE T4/T4 12MM,10538552,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II LT SZ7,10538553,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II LT SZ7,10538553,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Fiducial Markers Polymark 1x3mm 18g,10538555,CDM,0278,RC,C1739,HCPCS,,,,,,inpatient,facility,,,404.00,121.20,156.75,343.40,,,,,,,,,,,,,,,,,,,,156.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.40,,,percent of total billed charges,,,181.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Fiducial Markers Polymark 1x3mm 18g,10538555,CDM,0278,RC,C1739,HCPCS,,,,,,outpatient,facility,,,404.00,121.20,171.70,343.40,,,,,,,,,,,,,,,,,,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Fiducial Markers Polymark 1x3mm 18g,10538555,CDM,0278,RC,C1739,HCPCS,02055,APC,,,,outpatient,facility,,,404.00,121.20,136.20,396.27,,,,,,,,136.20,,,fee schedule,,,,,,,,,,,,,,,287.69,,,fee schedule,,,,,,,,,175.27,,,fee schedule,,,396.27,,,fee schedule,,,,,,,,,171.83,,,fee schedule,,,,,,,,,,,,,,,283.52,,,fee schedule,,,,,,,,,136.20,,,fee schedule,,,,,,,,,138.92,,,fee schedule,,,,,,,,,171.83,,,fee schedule,,,,,,,,,,,,,,,138.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.83,,,fee schedule,,,,,,,,,,,,,,,136.20,,,fee schedule,,,,,,,,,137.56,,,fee schedule,,,,,,,,
IMPLANT BRST INSPIRA SSF 265CC,10538556,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSF 265CC,10538556,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12/14 TPR 36MM 3.5MM,10538557,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12/14 TPR 36MM 3.5MM,10538557,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 14X14X34MM -8,10538558,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 14X14X34MM -8,10538558,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 4H 54MM SZ F,10538559,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 4H 54MM SZ F,10538559,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM M/L TAPER SZ10 X119MM,10538560,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM M/L TAPER SZ10 X119MM,10538560,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL KNEE CEMENTED 63MM,10538562,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL KNEE CEMENTED 63MM,10538562,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUTTON PATELLA KNEE 25X8MM,10538564,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUTTON PATELLA KNEE 25X8MM,10538564,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH MINI TREK II RE 1.2X06MM,10542595,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.63,395.25,,287.37,,,percent of total billed charges,,,,,,,,service not payable,226.92,,,percent of total billed charges,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.63,,,percent of total billed charges,,,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,302.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE PT 3.2MMX9IN,10542596,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE PT 3.2MMX9IN,10542596,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 16MM 6.5X35MM,10542597,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 16MM 6.5X35MM,10542597,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X40MM,10542598,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X40MM,10542598,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X35MM,10542599,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X35MM,10542599,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS OPEN BOX RT 75MM,10542600,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS OPEN BOX RT 75MM,10542600,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL 79-83X10MM,10542601,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL 79-83X10MM,10542601,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING VIVACIT-E 71-75X14MM,10542602,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING VIVACIT-E 71-75X14MM,10542602,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING VIVACIT-E 71-75X12MM,10542603,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING VIVACIT-E 71-75X12MM,10542603,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID SZ 3 3 PEG,10542604,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4205.00,1261.50,1631.54,3574.25,,,,,,,,,,,,,,,,,,,,1631.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3574.25,,,percent of total billed charges,,,1892.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID SZ 3 3 PEG,10542604,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4205.00,1261.50,1787.12,3574.25,,,,,,,,,,,,,service not payable,,,,,,,2121.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1787.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3153.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2102.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3153.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3574.25,,,percent of total billed charges,,,1934.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STEM FREE 46X16MM,10542605,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5852.00,1755.60,2270.58,4974.20,,2867.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2457.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2270.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2487.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4389.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4974.20,,,percent of total billed charges,,,2633.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STEM FREE 46X16MM,10542605,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5852.00,1755.60,2457.84,4974.20,,2867.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2457.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2951.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2487.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4389.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4389.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4974.20,,,percent of total billed charges,,,2691.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR HUM STEM FREE MD 28X19,10542606,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,25816.00,7744.80,10016.61,21943.60,,12649.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10842.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10016.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10971.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19362.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12908.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21943.60,,,percent of total billed charges,,,11617.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR HUM STEM FREE MD 28X19,10542606,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,25816.00,7744.80,10842.72,21943.60,,12649.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10842.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13021.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10971.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19362.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12908.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19362.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21943.60,,,percent of total billed charges,,,11875.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL 71-75X12MM,10542607,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL 71-75X12MM,10542607,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM STEM RT 65IN RT,10542608,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11227.00,3368.10,4356.08,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4356.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9542.95,,,percent of total billed charges,,,5052.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM STEM RT 65IN RT,10542608,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11227.00,3368.10,4715.34,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5662.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9542.95,,,percent of total billed charges,,,5164.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY INSTRUMENT TIBIAL 71MM,10542609,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY INSTRUMENT TIBIAL 71MM,10542609,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB MODULAR FINNED 10X80,10542610,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB MODULAR FINNED 10X80,10542610,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM STEM LT 65IN,10542611,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11227.00,3368.10,4356.08,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4356.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9542.95,,,percent of total billed charges,,,5052.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM STEM LT 65IN,10542611,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11227.00,3368.10,4715.34,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5662.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9542.95,,,percent of total billed charges,,,5164.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB VANG 79-83X10MM,10542612,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB VANG 79-83X10MM,10542612,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 13.5,10542613,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,4349.00,1304.70,1687.41,3696.65,,,,,,,,,,,,,,,,,,,,1687.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3696.65,,,percent of total billed charges,,,1957.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 13.5,10542613,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,4349.00,1304.70,1848.32,3696.65,,,,,,,,,,,,,service not payable,,,,,,,2193.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1848.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3696.65,,,percent of total billed charges,,,2000.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 5X60MM 6F,10542615,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 5X60MM 6F,10542615,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 5X80MM 6F,10542616,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 5X80MM 6F,10542616,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 5X100MM 6F,10542617,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 5X100MM 6F,10542617,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 5X120MM 6F,10542618,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4043.00,1212.90,1568.68,3436.55,,,,,,,,,,,,,,,,,,,,1568.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.55,,,percent of total billed charges,,,1819.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 5X120MM 6F,10542618,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4043.00,1212.90,1718.27,3436.55,,,,,,,,,,,,,service not payable,,,,,,,2039.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3436.55,,,percent of total billed charges,,,1859.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 6X100MM 6F,10542619,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 6X100MM 6F,10542619,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 6X120MM 6F,10542620,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4043.00,1212.90,1568.68,3436.55,,,,,,,,,,,,,,,,,,,,1568.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.55,,,percent of total billed charges,,,1819.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 6X120MM 6F,10542620,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4043.00,1212.90,1718.27,3436.55,,,,,,,,,,,,,service not payable,,,,,,,2039.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3436.55,,,percent of total billed charges,,,1859.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 7X100MM 6F,10542621,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 7X100MM 6F,10542621,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 7X120MM 6F,10542622,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4043.00,1212.90,1568.68,3436.55,,,,,,,,,,,,,,,,,,,,1568.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.55,,,percent of total billed charges,,,1819.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 7X120MM 6F,10542622,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4043.00,1212.90,1718.27,3436.55,,,,,,,,,,,,,service not payable,,,,,,,2039.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3436.55,,,percent of total billed charges,,,1859.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 8X100MM 6F,10542623,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 8X100MM 6F,10542623,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 8X120MM 6F,10542624,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4043.00,1212.90,1568.68,3436.55,,,,,,,,,,,,,,,,,,,,1568.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.55,,,percent of total billed charges,,,1819.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 8X120MM 6F,10542624,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4043.00,1212.90,1718.27,3436.55,,,,,,,,,,,,,service not payable,,,,,,,2039.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1718.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3032.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2021.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3032.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3436.55,,,percent of total billed charges,,,1859.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PROTEGE 120CM 8X200MM 6F,10542625,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PROTEGE 120CM 8X200MM 6F,10542625,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 9X20MM 120CM,10542626,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 9X20MM 120CM,10542626,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 9X40MM 120CM,10542627,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 9X40MM 120CM,10542627,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 9X60MM 120CM,10542628,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 9X60MM 120CM,10542628,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 9X80MM 120CM,10542629,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 9X80MM 120CM,10542629,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 10X20MM 120CM,10542630,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 10X20MM 120CM,10542630,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 10X40MM 120CM,10542631,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 10X40MM 120CM,10542631,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 10X60MM 120CM,10542632,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 10X60MM 120CM,10542632,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 10X80MM 120CM,10542633,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 10X80MM 120CM,10542633,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 12X60MM 120CM,10542634,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 12X60MM 120CM,10542634,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 14X40MM 120CM,10542635,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 14X40MM 120CM,10542635,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 14X60MM 120CM,10542636,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 14X60MM 120CM,10542636,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY SE 14X80MM 120CM,10542637,CDM,0278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY SE 14X80MM 120CM,10542637,CDM,0278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 5X17MM 135CM,10542638,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 5X17MM 135CM,10542638,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 5X27MM 135CM,10542639,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 5X27MM 135CM,10542639,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 5X37MM 135CM,10542640,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 5X37MM 135CM,10542640,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 5X57MM 135CM,10542641,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 5X57MM 135CM,10542641,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 6X17MM 135CM,10542642,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 6X17MM 135CM,10542642,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 6X57MM 135CM,10542643,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 6X57MM 135CM,10542643,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 7X17MM 135CM,10542644,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 7X17MM 135CM,10542644,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 7X57MM 135CM,10542645,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 7X57MM 135CM,10542645,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 8X17MM 135CM,10542646,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 8X17MM 135CM,10542646,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 6F 0.035IN 9X17MM 135CM,10542647,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 6F 0.035IN 9X17MM 135CM,10542647,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7F 0.035IN 9X27MM 135CM,10542648,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7F 0.035IN 9X27MM 135CM,10542648,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7F 0.035IN 9X57MM 135CM,10542649,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7F 0.035IN 9X57MM 135CM,10542649,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7F 0.035IN 10X17MM 135CM,10542650,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7F 0.035IN 10X17MM 135CM,10542650,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7F 0.035IN 10X37MM 135CM,10542651,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7F 0.035IN 10X37MM 135CM,10542651,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT 7F 0.035IN 10X57MM 135CM,10542652,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT 7F 0.035IN 10X57MM 135CM,10542652,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Slitting of prepuce dorsal or lateral except new,10542885,CDM,0450,RC,54001,CPT,,,,,,outpatient,facility,,,4613.00,1383.90,774.0,3921.05,,2850.83,,,percent of total billed charges,,,,,,,,,2251.14,,,percent of total billed charges,,,2326.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3459.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3459.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3921.05,,,percent of total billed charges,,,2121.98,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Slitting of prepuce dorsal or lateral except new,10542885,CDM,0450,RC,54001,CPT,05373,APC,,,,outpatient,facility,,,4613.00,1383.90,942.13,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,942.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,942.13,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,942.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
Slitting of prepuce dorsal or lateral except new,10542885,CDM,0450,RC,54001,CPT,183,EAPG,,,,outpatient,facility,,,4613.00,1383.90,2742.88,8205.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8205.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6974.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2867.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2867.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2867.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2742.88,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3017.17,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CAGE LUM POST 6D 14X23X9MM,10543514,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10924.00,3277.20,4238.51,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4238.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9285.40,,,percent of total billed charges,,,4915.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE LUM POST 6D 14X23X9MM,10543514,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10924.00,3277.20,4588.08,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5510.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8193.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9285.40,,,percent of total billed charges,,,5025.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST BIOPSY 14G BARBELL,10543519,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,458.00,137.40,177.70,389.30,,,,,,,,,,,,,,,,,,,,177.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,343.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,389.30,,,percent of total billed charges,,,206.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BRST BIOPSY 14G BARBELL,10543519,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,458.00,137.40,194.65,389.30,,,,,,,,,,,,,service not payable,,,,,,,231.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,194.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,389.30,,,percent of total billed charges,,,210.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST BIOPSY 14G TRIBELL,10543520,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,458.00,137.40,177.70,389.30,,,,,,,,,,,,,,,,,,,,177.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,343.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,389.30,,,percent of total billed charges,,,206.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BRST BIOPSY 14G TRIBELL,10543520,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,458.00,137.40,194.65,389.30,,,,,,,,,,,,,service not payable,,,,,,,231.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,194.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,343.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,389.30,,,percent of total billed charges,,,210.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 7.5X60MM,10543521,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 7.5X60MM,10543521,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD LT SZ 10,10543522,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD LT SZ 10,10543522,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA KNEE CEMENTED 41X10MM,10543523,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE CEMENTED 41X10MM,10543523,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC LT 10-12 GH 12MM,10543524,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC LT 10-12 GH 12MM,10543524,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK 3.2X14MM,10543525,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK 3.2X14MM,10543525,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE STEMMED TIB SZ 4,10543527,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE STEMMED TIB SZ 4,10543527,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TREK RE 3.75X15MM,10543528,CDM,0278,RC,C1727,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CATH TREK RE 3.75X15MM,10543528,CDM,0278,RC,C1727,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUPPORT ELBOW TENNIS NEOP SM,10543529,CDM,0274,RC,L3702,HCPCS,,,,,,inpatient,facility,,,76.00,22.80,29.49,64.60,,,,,,,,,,,,,,,,,,,,29.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,57.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.60,,,percent of total billed charges,,,34.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUPPORT ELBOW TENNIS NEOP SM,10543529,CDM,0274,RC,L3702,HCPCS,,,,,,outpatient,facility,,,76.00,22.80,32.30,171.76,,,,,,,,74.78,,,fee schedule,,,,,,,,,38.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,157.32,,,fee schedule,,,76.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",76.28,,,fee schedule,,,171.76,,,fee schedule,,,,,,,,,74.78,,,fee schedule,,,,,,,,,32.30,,,percent of total billed charges,,Paid in addition to outpatient services ,155.04,,,fee schedule,,,57.0,,,percent of total billed charges,,,74.78,,,fee schedule,,,76.0,,,fee schedule,,,76.28,,,fee schedule,,,38.0,,,percent of total billed charges,,Paid in addition to outpatient services ,74.78,,,fee schedule,,,57.0,,,percent of total billed charges,,,76.0,,,fee schedule,,,76.28,,,fee schedule,,,,,,,,,64.60,,,percent of total billed charges,,,34.96,,,percent of total billed charges,,,,,,,,,,,,,,,74.78,,,fee schedule,,,,,,,,,,,,,,,74.78,,,fee schedule,,,,,,,,,74.78,,,fee schedule,,,,,,,,
SUPPORT ELBOW TENNIS NEOP LG,10543530,CDM,0274,RC,L3702,HCPCS,,,,,,inpatient,facility,,,76.00,22.80,29.49,64.60,,,,,,,,,,,,,,,,,,,,29.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,57.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.60,,,percent of total billed charges,,,34.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUPPORT ELBOW TENNIS NEOP LG,10543530,CDM,0274,RC,L3702,HCPCS,,,,,,outpatient,facility,,,76.00,22.80,32.30,171.76,,,,,,,,74.78,,,fee schedule,,,,,,,,,38.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,157.32,,,fee schedule,,,76.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",76.28,,,fee schedule,,,171.76,,,fee schedule,,,,,,,,,74.78,,,fee schedule,,,,,,,,,32.30,,,percent of total billed charges,,Paid in addition to outpatient services ,155.04,,,fee schedule,,,57.0,,,percent of total billed charges,,,74.78,,,fee schedule,,,76.0,,,fee schedule,,,76.28,,,fee schedule,,,38.0,,,percent of total billed charges,,Paid in addition to outpatient services ,74.78,,,fee schedule,,,57.0,,,percent of total billed charges,,,76.0,,,fee schedule,,,76.28,,,fee schedule,,,,,,,,,64.60,,,percent of total billed charges,,,34.96,,,percent of total billed charges,,,,,,,,,,,,,,,74.78,,,fee schedule,,,,,,,,,,,,,,,74.78,,,fee schedule,,,,,,,,,74.78,,,fee schedule,,,,,,,,
MESH OVITEX RESORB 1S 10X12CM X_F10246-1012G X_TEL,10543532,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,6373.00,1911.90,2472.72,5417.05,,3122.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2676.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2472.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2708.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4779.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3186.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5417.05,,,percent of total billed charges,,,2867.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH OVITEX RESORB 1S 10X12CM X_F10246-1012G X_TEL,10543532,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,6373.00,1911.90,2676.66,5417.05,,3122.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2676.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3214.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2708.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4779.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3186.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4779.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5417.05,,,percent of total billed charges,,,2931.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB VG VE 71-75X14MM,10543533,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB VG VE 71-75X14MM,10543533,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 65MM LT,10543534,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 65MM LT,10543534,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING KNEE TIBIAL 71-75X12MM,10543535,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE TIBIAL 71-75X12MM,10543535,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 70MM RT,10543536,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 70MM RT,10543536,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP 40MM  3MM,10543537,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP 40MM  3MM,10543537,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 1.3X145MM,10543538,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 1.3X145MM,10543538,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Quantiferon TB Gold,10543933,CDM,0300,RC,86480,CPT,,,,,,outpatient,facility,,,207.00,62.10,58.88,207.0,,207.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,60.74,,,fee schedule,,,196.54,,,fee schedule,,,129.26,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,128.30,,,fee schedule,,,58.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",61.95,,,fee schedule,,,140.07,,,fee schedule,,,,,,,,,60.74,,,fee schedule,,,,,,,,,79.62,,,fee schedule,,,126.44,,,fee schedule,,,155.25,,,percent of total billed charges,,,60.74,,,fee schedule,,,58.88,,,fee schedule,,,61.95,,,fee schedule,,,93.64,,,fee schedule,,,60.74,,,fee schedule,,,155.25,,,percent of total billed charges,,,,,,,,,61.95,,,fee schedule,,,,,,,,,175.95,,,percent of total billed charges,,,95.22,,,percent of total billed charges,,,,,,,,,68.18,,,fee schedule,,,60.74,,,fee schedule,,,,,,,,,60.12,,,fee schedule,,,60.74,,,fee schedule,,,,,,,,,61.35,,,fee schedule,,,,,,,,
Quantiferon TB Gold,10543933,CDM,0300,RC,86480,CPT,395,EAPG,,,,outpatient,facility,,,207.00,62.10,48.13,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Mod AFB for Cryptosporidium,10544453,CDM,0300,RC,87206,CPT,,,,,,outpatient,facility,,,64.00,19.20,5.12,54.40,,22.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.28,,,fee schedule,,,17.08,,,fee schedule,,,11.24,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,11.16,,,fee schedule,,,5.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5.39,,,fee schedule,,,12.18,,,fee schedule,,,,,,,,,5.28,,,fee schedule,,,,,,,,,6.73,,,fee schedule,,,11.0,,,fee schedule,,,48.0,,,percent of total billed charges,,,5.28,,,fee schedule,,,5.12,,,fee schedule,,,5.39,,,fee schedule,,,7.92,,,fee schedule,,,5.28,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,5.39,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,5.93,,,fee schedule,,,5.28,,,fee schedule,,,,,,,,,5.23,,,fee schedule,,,5.28,,,fee schedule,,,,,,,,,5.33,,,fee schedule,,,,,,,,
Mod AFB for Cryptosporidium,10544453,CDM,0300,RC,87206,CPT,396,EAPG,,,,outpatient,facility,,,64.00,19.20,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DOME INBONE TALAR SZ3 36X36X10,10544571,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15883.00,4764.90,6162.60,13500.55,,7782.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6670.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6162.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6750.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7941.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13500.55,,,percent of total billed charges,,,7147.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOME INBONE TALAR SZ3 36X36X10,10544571,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15883.00,4764.90,6670.86,13500.55,,7782.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6670.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8011.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6750.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7941.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11912.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13500.55,,,percent of total billed charges,,,7306.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP LT SHORT 2.7X40MM,10544572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4455.00,1336.50,1728.54,3786.75,,,,,,,,,,,,,,,,,,,,1728.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1893.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2227.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3786.75,,,percent of total billed charges,,,2004.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP LT SHORT 2.7X40MM,10544572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4455.00,1336.50,1893.38,3786.75,,,,,,,,,,,,,service not payable,,,,,,,2247.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1893.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2227.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3341.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3786.75,,,percent of total billed charges,,,2049.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LK ST 2.7X50MM,10544573,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LK ST 2.7X50MM,10544573,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2.0X24MM,10544574,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2.0X24MM,10544574,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 8X22MM,10544575,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 8X22MM,10544575,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2.7X55MM,10544577,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,941.00,282.30,365.11,799.85,,,,,,,,,,,,,,,,,,,,365.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,705.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,470.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.85,,,percent of total billed charges,,,423.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2.7X55MM,10544577,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,941.00,282.30,399.93,799.85,,,,,,,,,,,,,service not payable,,,,,,,474.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,399.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,705.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,470.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,705.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,799.85,,,percent of total billed charges,,,432.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE COMP 1.6X25X150MM,10544578,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE COMP 1.6X25X150MM,10544578,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ANG LKING 2.4X24MM,10544579,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ANG LKING 2.4X24MM,10544579,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ANG LKING 2.4X26MM,10544580,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ANG LKING 2.4X26MM,10544580,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CVRD SMOOTH 5.5X60MM,10544581,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CVRD SMOOTH 5.5X60MM,10544581,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD XIA3 RADIAL 6.0X100.0MM,10544582,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,536.00,160.80,207.97,455.60,,,,,,,,,,,,,,,,,,,,207.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.60,,,percent of total billed charges,,,241.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD XIA3 RADIAL 6.0X100.0MM,10544582,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,536.00,160.80,227.80,455.60,,,,,,,,,,,,,service not payable,,,,,,,270.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,402.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,455.60,,,percent of total billed charges,,,246.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 52X21MM,10544585,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11782.00,3534.60,4571.42,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4571.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10014.70,,,percent of total billed charges,,,5301.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 52X21MM,10544585,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11782.00,3534.60,4948.44,10014.70,,5773.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4948.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5942.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5007.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10014.70,,,percent of total billed charges,,,5419.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID 35D LARGE AUG RIGHT,10544586,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12248.00,3674.40,4752.22,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4752.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10410.80,,,percent of total billed charges,,,5511.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID 35D LARGE AUG RIGHT,10544586,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12248.00,3674.40,5144.16,10410.80,,6001.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5144.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6177.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5205.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9186.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6124.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9186.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10410.80,,,percent of total billed charges,,,5634.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR RIGHT SZ 7,10544587,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR RIGHT SZ 7,10544587,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIA PSN REV FX SZD LT,10544588,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIA PSN REV FX SZD LT,10544588,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK TIB PERS HLF LL SZCD 5MM,10544589,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK TIB PERS HLF LL SZCD 5MM,10544589,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT OFFSET 6MM 12X135MM,10544590,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT OFFSET 6MM 12X135MM,10544590,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE LT 6-9 CD 10MM,10544591,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE LT 6-9 CD 10MM,10544591,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT JUGGERKNOT CN 2.9MM,10544592,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1300.00,390.00,504.40,1105.0,,,,,,,,,,,,,,,,,,,,504.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,975.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,650.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1105.0,,,percent of total billed charges,,,585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT JUGGERKNOT CN 2.9MM,10544592,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1300.00,390.00,552.5,1105.0,,,,,,,,,,,,,service not payable,,,,,,,655.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,552.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,975.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,650.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,975.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1105.0,,,percent of total billed charges,,,598.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAPTER TAPER -6MM NECK,10544593,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADAPTER TAPER -6MM NECK,10544593,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC PPS SZ 7,10544594,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC PPS SZ 7,10544594,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE G7 LPR DOME 6.5X15,10544595,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE G7 LPR DOME 6.5X15,10544595,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X40MM,10544597,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X40MM,10544597,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC PPS SZ 8,10544598,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC PPS SZ 8,10544598,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB NAT NAIL 10MMX34CM,10544601,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4443.00,1332.90,1723.88,3776.55,,,,,,,,,,,,,,,,,,,,1723.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1888.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3332.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2221.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3776.55,,,percent of total billed charges,,,1999.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB NAT NAIL 10MMX34CM,10544601,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4443.00,1332.90,1888.27,3776.55,,,,,,,,,,,,,service not payable,,,,,,,2241.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1888.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3332.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2221.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3332.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3776.55,,,percent of total billed charges,,,2043.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER PEEL-A-WAY 22F,10544602,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,248.00,74.40,105.40,210.80,,153.26,,,percent of total billed charges,,,,,,,,service not payable,121.02,,,percent of total billed charges,,,125.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,105.40,,,percent of total billed charges,,,,,,,,,186.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,124.0,,,percent of total billed charges,,,,,,,,service not payable,186.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,210.80,,,percent of total billed charges,,,114.08,,,percent of total billed charges,,,,,,,,,161.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,161.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTRODUCER PEEL-A-WAY 20F,10544603,CDM,0278,RC,C1894,HCPCS,,,,,,inpatient,facility,,,248.00,74.40,96.22,210.80,,,,,,,,,,,,,,,,,,,,96.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,186.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.80,,,percent of total billed charges,,,111.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTRODUCER PEEL-A-WAY 20F,10544603,CDM,0278,RC,C1894,HCPCS,,,,,,outpatient,facility,,,248.00,74.40,105.40,210.80,,,,,,,,,,,,,service not payable,,,,,,,125.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,105.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,186.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,124.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,186.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,210.80,,,percent of total billed charges,,,114.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC PROX TAP 38X167,10544604,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,37011.00,11103.30,14360.27,31459.35,,18135.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15544.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14360.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15729.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27758.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18505.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31459.35,,,percent of total billed charges,,,16654.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC PROX TAP 38X167,10544604,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,37011.00,11103.30,15544.62,31459.35,,18135.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15544.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18668.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15729.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27758.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18505.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27758.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31459.35,,,percent of total billed charges,,,17025.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC PROX TAP 38X217,10544605,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,37011.00,11103.30,14360.27,31459.35,,18135.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15544.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14360.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15729.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27758.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18505.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31459.35,,,percent of total billed charges,,,16654.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC PROX TAP 38X217,10544605,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,37011.00,11103.30,15544.62,31459.35,,18135.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15544.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18668.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15729.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27758.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18505.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27758.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,31459.35,,,percent of total billed charges,,,17025.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT MAT NEOPRENE LF 18X24,10544606,CDM,0273,RC,L3908,HCPCS,,,,,,outpatient,facility,,,155.00,46.50,46.09,151.67,,95.79,,,percent of total billed charges,,,66.04,,,fee schedule,,,75.64,,,percent of total billed charges,,,78.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,138.92,,,fee schedule,,,46.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",67.36,,,fee schedule,,,151.67,,,fee schedule,,,,,,,,,66.04,,,fee schedule,,,,,,,,,65.88,,,percent of total billed charges,,,136.90,,,fee schedule,,,116.25,,,percent of total billed charges,,,66.04,,,fee schedule,,,46.09,,,fee schedule,,,67.36,,,fee schedule,,,77.5,,,percent of total billed charges,,,66.04,,,fee schedule,,,116.25,,,percent of total billed charges,,,46.09,,,fee schedule,,,67.36,,,fee schedule,,,,,,,,,131.75,,,percent of total billed charges,,,71.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,66.04,,,fee schedule,,,,,,,,,66.70,,,fee schedule,,,,,,,,
CATH ANGIOGRAPHY 4F STR 65CM X_31-510 X_BOSTON SCI,10544607,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY 4F STR 100CM,10544608,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY BERN 4F 100CM X_31-606 X_BOSTON S,10544609,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANG CONTALATERAL 4F 65CM,10544610,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 17.0D,10544612,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 17.0D,10544612,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 18.0D,10544613,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 18.0D,10544613,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CANNULA DILATOR ANGLE 180D,10544614,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,28411.00,8523.30,12074.67,24149.35,,17558.0,,,percent of total billed charges,,,,,,,,service not payable,13864.57,,,percent of total billed charges,,,14330.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12074.67,,,percent of total billed charges,,,,,,,,,21308.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14205.5,,,percent of total billed charges,,,,,,,,service not payable,21308.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24149.35,,,percent of total billed charges,,,13069.06,,,percent of total billed charges,,,,,,,,,18467.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,18467.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CANNULA DILATOR ANGLE 20D,10544615,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,28411.00,8523.30,12074.67,24149.35,,17558.0,,,percent of total billed charges,,,,,,,,service not payable,13864.57,,,percent of total billed charges,,,14330.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12074.67,,,percent of total billed charges,,,,,,,,,21308.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14205.5,,,percent of total billed charges,,,,,,,,service not payable,21308.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24149.35,,,percent of total billed charges,,,13069.06,,,percent of total billed charges,,,,,,,,,18467.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,18467.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CANNULA PERF-V BBL TRAP 180D,10544617,CDM,0272,RC,C1881,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,1959.06,,,percent of total billed charges,,,,,,,,service not payable,1546.96,,,percent of total billed charges,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1585.0,,,percent of total billed charges,,,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,2060.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2060.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CANNULA PERF-V BBL TRAP 20D,10544618,CDM,0272,RC,C1881,HCPCS,,,,,,outpatient,facility,,,31689.00,9506.70,13467.83,26935.65,,19583.80,,,percent of total billed charges,,,,,,,,service not payable,15464.23,,,percent of total billed charges,,,15983.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13467.83,,,percent of total billed charges,,,,,,,,,23766.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15844.5,,,percent of total billed charges,,,,,,,,service not payable,23766.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26935.65,,,percent of total billed charges,,,14576.94,,,percent of total billed charges,,,,,,,,,20597.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,20597.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH KIT HEMODIALYSIS 28CM,10544619,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.58,1393.15,,1012.9,,,percent of total billed charges,,,,,,,,service not payable,799.83,,,percent of total billed charges,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.58,,,percent of total billed charges,,,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,1065.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1065.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH PLEURX PLEURAL LK,10544621,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,186.00,55.80,79.05,158.10,,114.95,,,percent of total billed charges,,,,,,,,service not payable,90.77,,,percent of total billed charges,,,93.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,79.05,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,93.0,,,percent of total billed charges,,,,,,,,service not payable,139.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,,85.56,,,percent of total billed charges,,,,,,,,,120.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,120.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPLINT WRIST LTHRT MALL L XL,10544622,CDM,0270,RC,L3908,HCPCS,,,,,,outpatient,facility,,,54.00,16.20,22.95,122.04,,33.37,,,percent of total billed charges,,,53.14,,,fee schedule,,,26.35,,,percent of total billed charges,,,27.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,111.78,,,fee schedule,,,46.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",54.20,,,fee schedule,,,122.04,,,fee schedule,,,,,,,,,53.14,,,fee schedule,,,,,,,,,22.95,,,percent of total billed charges,,,110.16,,,fee schedule,,,40.5,,,percent of total billed charges,,,53.14,,,fee schedule,,,46.09,,,fee schedule,,,54.20,,,fee schedule,,,27.0,,,percent of total billed charges,,,53.14,,,fee schedule,,,40.5,,,percent of total billed charges,,,46.09,,,fee schedule,,,54.20,,,fee schedule,,,,,,,,,45.90,,,percent of total billed charges,,,24.84,,,percent of total billed charges,,,,,,,,,35.10,,,percent of total billed charges,,,53.14,,,fee schedule,,,,,,,,,35.10,,,percent of total billed charges,,,53.14,,,fee schedule,,,,,,,,,53.14,,,fee schedule,,,,,,,,
SPLINT WRIST LEATHERETTE RT XL,10544623,CDM,0270,RC,L3908,HCPCS,,,,,,outpatient,facility,,,54.00,16.20,22.95,122.04,,33.37,,,percent of total billed charges,,,53.14,,,fee schedule,,,26.35,,,percent of total billed charges,,,27.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,111.78,,,fee schedule,,,46.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",54.20,,,fee schedule,,,122.04,,,fee schedule,,,,,,,,,53.14,,,fee schedule,,,,,,,,,22.95,,,percent of total billed charges,,,110.16,,,fee schedule,,,40.5,,,percent of total billed charges,,,53.14,,,fee schedule,,,46.09,,,fee schedule,,,54.20,,,fee schedule,,,27.0,,,percent of total billed charges,,,53.14,,,fee schedule,,,40.5,,,percent of total billed charges,,,46.09,,,fee schedule,,,54.20,,,fee schedule,,,,,,,,,45.90,,,percent of total billed charges,,,24.84,,,percent of total billed charges,,,,,,,,,35.10,,,percent of total billed charges,,,53.14,,,fee schedule,,,,,,,,,35.10,,,percent of total billed charges,,,53.14,,,fee schedule,,,,,,,,,53.14,,,fee schedule,,,,,,,,
LIFESTENT 5F 135CM 7X60MM,10544624,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIFESTENT 5F 135CM 7X60MM,10544624,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL 1 THORACIC 2.3X15MM,10544626,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,913.00,273.90,354.24,776.05,,,,,,,,,,,,,,,,,,,,354.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,,410.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL 1 THORACIC 2.3X15MM,10544626,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,913.00,273.90,388.02,776.05,,,,,,,,,,,,,service not payable,,,,,,,460.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,684.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,,419.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL 1 THORACIC 2.3 X 17M,10544627,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,913.00,273.90,354.24,776.05,,,,,,,,,,,,,,,,,,,,354.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,,410.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL 1 THORACIC 2.3 X 17M,10544627,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,913.00,273.90,388.02,776.05,,,,,,,,,,,,,service not payable,,,,,,,460.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,684.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,,419.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL 1 THORACIC 8H,10544628,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4232.00,1269.60,1642.02,3597.20,,,,,,,,,,,,,,,,,,,,1642.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1798.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3174.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2116.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3597.20,,,percent of total billed charges,,,1904.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL 1 THORACIC 8H,10544628,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4232.00,1269.60,1798.60,3597.20,,,,,,,,,,,,,service not payable,,,,,,,2134.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1798.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3174.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2116.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3174.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3597.20,,,percent of total billed charges,,,1946.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL 1 THORACIC 18H,10544629,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3715.00,1114.50,1441.42,3157.75,,,,,,,,,,,,,,,,,,,,1441.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3157.75,,,percent of total billed charges,,,1671.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL 1 THORACIC 18H,10544629,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3715.00,1114.50,1578.88,3157.75,,,,,,,,,,,,,service not payable,,,,,,,1873.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1578.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2786.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1857.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2786.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3157.75,,,percent of total billed charges,,,1708.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB UNI JRNY 3-4 10MM,10544630,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB UNI JRNY 3-4 10MM,10544630,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETABULAR G7 MH SZH 64M,10544631,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11080.00,3324.00,4299.04,9418.0,,5429.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4653.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4299.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8310.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5540.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9418.0,,,percent of total billed charges,,,4986.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR G7 MH SZH 64M,10544631,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11080.00,3324.00,4653.60,9418.0,,5429.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4653.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5588.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4709.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8310.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5540.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8310.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9418.0,,,percent of total billed charges,,,5096.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE PUTTY STIM DBM 2.55,10544632,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE PUTTY STIM DBM 2.55,10544632,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE PUTTY STIM DBM 2.55,10544632,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,2405.00,721.50,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 19MM HAART 300,10545100,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 19MM HAART 300,10545100,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 21MM HAART 300,10545101,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 21MM HAART 300,10545101,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 23MM HAART 300,10545102,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 23MM HAART 300,10545102,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 25MM HAART 300,10545103,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 25MM HAART 300,10545103,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 19MM HAART 200,10545104,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 19MM HAART 200,10545104,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 21MM HAART 200,10545105,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 21MM HAART 200,10545105,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 23MM HAART 200,10545106,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 23MM HAART 200,10545106,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AORTIC 25MM HAART 200,10545107,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AORTIC 25MM HAART 200,10545107,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF TI 10X11X34MM,10545112,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF TI 10X11X34MM,10545112,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB ART BCS SZ -3-4 RT,10545113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB ART BCS SZ -3-4 RT,10545113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT INFINITY POLY SZ1 8MM,10545114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6429.00,1928.70,2494.45,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2494.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5464.65,,,percent of total billed charges,,,2893.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT INFINITY POLY SZ1 8MM,10545114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6429.00,1928.70,2700.18,5464.65,,3150.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3242.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2732.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4821.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3214.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4821.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5464.65,,,percent of total billed charges,,,2957.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING VIV VANG 71-75X12MM,10545115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING VIV VANG 71-75X12MM,10545115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM MOD 40MM PLUS 6MM,10545116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM MOD 40MM PLUS 6MM,10545116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE FLUTED TIB SZ 5,10545117,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE FLUTED TIB SZ 5,10545117,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ F LT 5-7X12MM,10545118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ F LT 5-7X12MM,10545118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ G LT,10545119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ G LT,10545119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ G XL 6-8X12MM,10545120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ G XL 6-8X12MM,10545120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS-FLEX GSF RT SZ F,10545124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS-FLEX GSF RT SZ F,10545124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ2 9MM,10545125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ2 9MM,10545125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR LT 10-12 11MM,10545126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR LT 10-12 11MM,10545126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE DXTEND D42MM 2MM,10545127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE DXTEND D42MM 2MM,10545127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 LF 4 9MM,10545129,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 LF 4 9MM,10545129,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER BRST TUMARK X SHP 12CM,10545131,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MARKER BRST TUMARK X SHP 12CM,10545131,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE HIP ACROS REV SZ C 60MM,10546547,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21112.00,6333.60,8191.46,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8191.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17945.20,,,percent of total billed charges,,,9500.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE HIP ACROS REV SZ C 60MM,10546547,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21112.00,6333.60,8867.04,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10648.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17945.20,,,percent of total billed charges,,,9711.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LP SS 4.0X50MM,10546548,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LP SS 4.0X50MM,10546548,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CONTOURED 5.5X30MM,10546549,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CONTOURED 5.5X30MM,10546549,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING KNEE TIBIAL 79/83X14MM,10546550,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE TIBIAL 79/83X14MM,10546550,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 135D 10X130MM,10546551,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 135D 10X130MM,10546551,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPHERE REV CTR GLENOID 25X42MM,10546747,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8392.00,2517.60,3256.10,7133.20,,4112.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3524.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3256.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3566.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7133.20,,,percent of total billed charges,,,3776.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPHERE REV CTR GLENOID 25X42MM,10546747,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8392.00,2517.60,3524.64,7133.20,,4112.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3524.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4232.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3566.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7133.20,,,percent of total billed charges,,,3860.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FEM NECK SYS 100MM,10546748,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2091.00,627.30,811.31,1777.35,,,,,,,,,,,,,,,,,,,,811.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,888.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1568.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1777.35,,,percent of total billed charges,,,940.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FEM NECK SYS 100MM,10546748,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2091.00,627.30,888.67,1777.35,,,,,,,,,,,,,service not payable,,,,,,,1054.7,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,888.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1568.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1568.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1777.35,,,percent of total billed charges,,,961.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2H FEM NECK SYS,10546749,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3764.00,1129.20,1460.43,3199.40,,,,,,,,,,,,,,,,,,,,1460.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1599.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2823.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1882.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3199.40,,,percent of total billed charges,,,1693.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2H FEM NECK SYS,10546749,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3764.00,1129.20,1599.7,3199.40,,,,,,,,,,,,,service not payable,,,,,,,1898.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1599.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2823.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1882.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2823.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3199.40,,,percent of total billed charges,,,1731.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT FEM NECK SYS 100MM,10546750,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2482.00,744.60,963.02,2109.70,,,,,,,,,,,,,,,,,,,,963.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1054.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1861.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1241.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2109.70,,,percent of total billed charges,,,1116.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT FEM NECK SYS 100MM,10546750,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2482.00,744.60,1054.85,2109.70,,,,,,,,,,,,,service not payable,,,,,,,1251.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1054.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1861.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1241.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1861.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2109.70,,,percent of total billed charges,,,1141.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG ST 5.0X44MM,10546751,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1688.00,506.40,654.94,1434.8,,,,,,,,,,,,,,,,,,,,654.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1266.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1434.8,,,percent of total billed charges,,,759.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG ST 5.0X44MM,10546751,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1688.00,506.40,717.40,1434.8,,,,,,,,,,,,,service not payable,,,,,,,851.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,717.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1266.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1266.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1434.8,,,percent of total billed charges,,,776.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG HOLE G7 APICAL,10546893,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG HOLE G7 APICAL,10546893,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 VIT 40MM,10546894,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 VIT 40MM,10546894,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE ARCOS SZ C 60MM,10546895,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21112.00,6333.60,8191.46,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8191.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17945.20,,,percent of total billed charges,,,9500.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE ARCOS SZ C 60MM,10546895,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21112.00,6333.60,8867.04,17945.20,,10344.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8867.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10648.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8972.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10556.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15834.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17945.20,,,percent of total billed charges,,,9711.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM ARCOS DIST 17X150MM,10546896,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10885.00,3265.50,4223.38,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4223.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9252.25,,,percent of total billed charges,,,4898.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM ARCOS DIST 17X150MM,10546896,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10885.00,3265.50,4571.70,9252.25,,5333.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4571.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5490.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4626.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9252.25,,,percent of total billed charges,,,5007.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROTECTOR NERVE 10X40MM,10546897,CDM,0278,RC,C9353,HCPCS,,,,,,inpatient,facility,,,8593.00,2577.90,3334.08,7304.05,,4210.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3609.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3334.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3652.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6444.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4296.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7304.05,,,percent of total billed charges,,,3866.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTECTOR NERVE 10X40MM,10546897,CDM,0278,RC,C9353,HCPCS,,,,,,outpatient,facility,,,8593.00,2577.90,3609.06,7304.05,,4210.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3609.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4334.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3652.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6444.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4296.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6444.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7304.05,,,percent of total billed charges,,,3952.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROTECTOR NERVE 10X40MM,10546897,CDM,0278,RC,C9353,HCPCS,455,EAPG,,,,outpatient,facility,,,8593.00,2577.90,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CONDYLE RT SZ 6,10546929,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7872.00,2361.60,3054.34,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3054.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6691.20,,,percent of total billed charges,,,3542.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CONDYLE RT SZ 6,10546929,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7872.00,2361.60,3306.24,6691.20,,3857.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3306.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3970.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3345.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5904.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3936.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5904.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6691.20,,,percent of total billed charges,,,3621.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH LIGHTNING 12 115CM,10548440,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,22325.00,6697.50,9488.13,18976.25,,13796.85,,,percent of total billed charges,,,,,,,,service not payable,10894.6,,,percent of total billed charges,,,11260.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9488.13,,,percent of total billed charges,,,,,,,,,16743.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11162.5,,,percent of total billed charges,,,,,,,,service not payable,16743.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18976.25,,,percent of total billed charges,,,10269.5,,,percent of total billed charges,,,,,,,,,14511.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,14511.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LOW PROF 3.5X35MM,10550544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LOW PROF 3.5X35MM,10550544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BIOCOMP INTERF 7X20MM,10550545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BIOCOMP INTERF 7X20MM,10550545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEX TI 12X2.3STR,10550546,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEX TI 12X2.3STR,10550546,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK HEX TI 14X2.3STR,10550547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK HEX TI 14X2.3STR,10550547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FUSION TOT WR FUSION,10550548,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3294.00,988.20,1278.07,2799.90,,,,,,,,,,,,,,,,,,,,1278.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2799.90,,,percent of total billed charges,,,1482.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FUSION TOT WR FUSION,10550548,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3294.00,988.20,1399.95,2799.90,,,,,,,,,,,,,service not payable,,,,,,,1661.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1399.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2470.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1647.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2470.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2799.90,,,percent of total billed charges,,,1515.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 3.5X10MM,10550549,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 3.5X10MM,10550549,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DISTAL TIB LCKG 8H RT,10550550,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4707.00,1412.10,1826.32,4000.95,,,,,,,,,,,,,,,,,,,,1826.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2000.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3530.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2353.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4000.95,,,percent of total billed charges,,,2118.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DISTAL TIB LCKG 8H RT,10550550,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4707.00,1412.10,2000.47,4000.95,,,,,,,,,,,,,service not payable,,,,,,,2374.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2000.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3530.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2353.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3530.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4000.95,,,percent of total billed charges,,,2165.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X28MM,10550551,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X28MM,10550551,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X42MM,10550552,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X42MM,10550552,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MARKER US TUMARK VIS 12CM,10550553,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,525.00,157.50,223.13,446.25,,324.45,,,percent of total billed charges,,,,,,,,service not payable,256.20,,,percent of total billed charges,,,264.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,223.13,,,percent of total billed charges,,,,,,,,,393.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,service not payable,393.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,,241.5,,,percent of total billed charges,,,,,,,,,341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,341.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Anes moderate sedation by other phys initial 15 mi,10550668,CDM,0379,RC,99156,CPT,,,,,,outpatient,facility,,,475.00,142.50,201.88,403.75,,293.55,,,percent of total billed charges,,,,,,,,service not payable,231.80,,,percent of total billed charges,,,239.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,201.88,,,percent of total billed charges,,,,,,,,,356.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,237.5,,,percent of total billed charges,,,,,,,,service not payable,356.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,403.75,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,308.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,308.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Anes moderate sedation by other phys initial 15 mi,10550668,CDM,0379,RC,99156,CPT,380,EAPG,,,,outpatient,facility,,,475.00,142.50,33.12,65.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,55.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.02,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,48.42,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DM-Amb Continuous Glucose Monitoring Interstitial,10550695,CDM,0510,RC,95249,CPT,,,,,,outpatient,facility,,,173.00,51.90,79.58,147.05,,106.91,,,percent of total billed charges,,,,,,,,,84.42,,,percent of total billed charges,,,87.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,129.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,147.05,,,percent of total billed charges,,,79.58,,,percent of total billed charges,,,,,,,,,112.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,
DM-Amb Continuous Glucose Monitoring Interstitial,10550695,CDM,0510,RC,95249,CPT,05733,APC,,,,outpatient,facility,,,173.00,51.90,54.63,130.83,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,119.83,,,fee schedule,,,54.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",58.10,,,fee schedule,,,130.83,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,118.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,54.63,,,fee schedule,,,58.10,,,fee schedule,,,,,,,,,56.96,,,fee schedule,,,,,,,,,54.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",58.10,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,,,,,,,56.96,,,fee schedule,,,,,,,,,57.53,,,fee schedule,,,,,,,,
DM-Amb Continuous Glucose Monitoring Interstitial,10550695,CDM,0510,RC,95249,CPT,428,EAPG,,,,outpatient,facility,,,173.00,51.90,181.66,528.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,528.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,449.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,199.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL GAMMA 3 RT 120D 10X380MM,10551339,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7021.00,2106.30,2724.15,5967.85,,3440.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2948.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2724.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2983.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5265.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3510.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5967.85,,,percent of total billed charges,,,3159.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL GAMMA 3 RT 120D 10X380MM,10551339,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7021.00,2106.30,2948.82,5967.85,,3440.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2948.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3541.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2983.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5265.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3510.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5265.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5967.85,,,percent of total billed charges,,,3229.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL GAMMA 3 RT 120D 10X360MM,10551340,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7021.00,2106.30,2724.15,5967.85,,3440.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2948.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2724.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2983.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5265.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3510.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5967.85,,,percent of total billed charges,,,3159.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL GAMMA 3 RT 120D 10X360MM,10551340,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7021.00,2106.30,2948.82,5967.85,,3440.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2948.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3541.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2983.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5265.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3510.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5265.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5967.85,,,percent of total billed charges,,,3229.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL 71-75X16MM,10551341,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL 71-75X16MM,10551341,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ENDOHEAD SZ 43MM,10551342,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ENDOHEAD SZ 43MM,10551342,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 63-67X10MM,10551343,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 63-67X10MM,10551343,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/3 TUBULAR 8H 97MM,10551345,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/3 TUBULAR 8H 97MM,10551345,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTCL Z NAIL 5.0X25 MM,10551346,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTCL Z NAIL 5.0X25 MM,10551346,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EDEMAWEAR CLOSED TOE - MEDIUM,10551349,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,81.00,24.30,30.36,68.85,,50.06,,,percent of total billed charges,,,,,,,,service not payable,39.53,,,percent of total billed charges,,,40.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,34.42,,,percent of total billed charges,,,,,,,,,60.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,,,service not payable,60.75,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,68.85,,,percent of total billed charges,,,37.26,,,percent of total billed charges,,,,,,,,,52.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,52.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPICA THUMB RT-LG/XL,10551350,CDM,0273,RC,L3807,HCPCS,,,,,,outpatient,facility,,,95.00,28.50,40.38,214.70,,58.71,,,percent of total billed charges,,,93.48,,,fee schedule,,,46.36,,,percent of total billed charges,,,47.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,196.65,,,fee schedule,,,95.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.35,,,fee schedule,,,214.70,,,fee schedule,,,,,,,,,93.48,,,fee schedule,,,,,,,,,40.38,,,percent of total billed charges,,,193.80,,,fee schedule,,,71.25,,,percent of total billed charges,,,93.48,,,fee schedule,,,95.0,,,fee schedule,,,95.35,,,fee schedule,,,47.5,,,percent of total billed charges,,,93.48,,,fee schedule,,,71.25,,,percent of total billed charges,,,95.0,,,fee schedule,,,95.35,,,fee schedule,,,,,,,,,80.75,,,percent of total billed charges,,,43.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,93.48,,,fee schedule,,,,,,,,,93.48,,,fee schedule,,,,,,,,
SPICA THUMB LT-SM/MD,10551351,CDM,0270,RC,L3807,HCPCS,,,,,,outpatient,facility,,,95.00,28.50,40.38,214.70,,58.71,,,percent of total billed charges,,,93.48,,,fee schedule,,,46.36,,,percent of total billed charges,,,47.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,196.65,,,fee schedule,,,95.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",95.35,,,fee schedule,,,214.70,,,fee schedule,,,,,,,,,93.48,,,fee schedule,,,,,,,,,40.38,,,percent of total billed charges,,,193.80,,,fee schedule,,,71.25,,,percent of total billed charges,,,93.48,,,fee schedule,,,95.0,,,fee schedule,,,95.35,,,fee schedule,,,47.5,,,percent of total billed charges,,,93.48,,,fee schedule,,,71.25,,,percent of total billed charges,,,95.0,,,fee schedule,,,95.35,,,fee schedule,,,,,,,,,80.75,,,percent of total billed charges,,,43.70,,,percent of total billed charges,,,,,,,,,61.75,,,percent of total billed charges,,,93.48,,,fee schedule,,,,,,,,,61.75,,,percent of total billed charges,,,93.48,,,fee schedule,,,,,,,,,93.48,,,fee schedule,,,,,,,,
KIT CANNULA ARTERIAL 19FR,10551353,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,2002.00,600.60,850.85,1701.7,,1237.24,,,percent of total billed charges,,,,,,,,service not payable,976.98,,,percent of total billed charges,,,1009.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,850.85,,,percent of total billed charges,,,,,,,,,1501.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1001.0,,,percent of total billed charges,,,,,,,,service not payable,1501.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1701.7,,,percent of total billed charges,,,920.92,,,percent of total billed charges,,,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CANNULA ARTERIAL 21FR,10551354,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,2002.00,600.60,850.85,1701.7,,1237.24,,,percent of total billed charges,,,,,,,,service not payable,976.98,,,percent of total billed charges,,,1009.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,850.85,,,percent of total billed charges,,,,,,,,,1501.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1001.0,,,percent of total billed charges,,,,,,,,service not payable,1501.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1701.7,,,percent of total billed charges,,,920.92,,,percent of total billed charges,,,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CANNULA ARTERIAL 23FR,10551355,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,2002.00,600.60,850.85,1701.7,,1237.24,,,percent of total billed charges,,,,,,,,service not payable,976.98,,,percent of total billed charges,,,1009.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,850.85,,,percent of total billed charges,,,,,,,,,1501.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1001.0,,,percent of total billed charges,,,,,,,,service not payable,1501.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1701.7,,,percent of total billed charges,,,920.92,,,percent of total billed charges,,,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CANNULA ARTERIAL 25FR,10551356,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,2002.00,600.60,850.85,1701.7,,1237.24,,,percent of total billed charges,,,,,,,,service not payable,976.98,,,percent of total billed charges,,,1009.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,850.85,,,percent of total billed charges,,,,,,,,,1501.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1001.0,,,percent of total billed charges,,,,,,,,service not payable,1501.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1701.7,,,percent of total billed charges,,,920.92,,,percent of total billed charges,,,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1301.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Pancreatic Elastase Fecal (3002858),10551647,CDM,0300,RC,82653,CPT,,,,,,outpatient,facility,,,110.00,33.00,21.82,93.5,,67.98,,,percent of total billed charges,,,22.51,,,fee schedule,,,54.12,,,fee schedule,,,47.91,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,47.55,,,fee schedule,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",22.96,,,fee schedule,,,51.91,,,fee schedule,,,,,,,,,22.51,,,fee schedule,,,,,,,,,29.49,,,fee schedule,,,46.86,,,fee schedule,,,82.5,,,percent of total billed charges,,,22.51,,,fee schedule,,,21.82,,,fee schedule,,,22.96,,,fee schedule,,,34.68,,,fee schedule,,,22.51,,,fee schedule,,,82.5,,,percent of total billed charges,,,,,,,,,22.96,,,fee schedule,,,,,,,,,93.5,,,percent of total billed charges,,,50.60,,,percent of total billed charges,,,,,,,,,25.27,,,fee schedule,,,22.51,,,fee schedule,,,,,,,,,22.28,,,fee schedule,,,22.51,,,fee schedule,,,,,,,,,22.74,,,fee schedule,,,,,,,,
Pancreatic Elastase Fecal (3002858),10551647,CDM,0300,RC,82653,CPT,400,EAPG,,,,outpatient,facility,,,110.00,33.00,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LENS TECNIS SYMFONY 16.5D 6MM,10551737,CDM,0276,RC,V2788,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS SYMFONY 16.5D 6MM,10551737,CDM,0276,RC,V2788,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1795.5,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,service not payable,1615.95,,,fee schedule,,,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 320CC,10551738,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 320CC,10551738,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 340CC,10551739,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 340CC,10551739,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 360CC,10551740,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 360CC,10551740,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 400CC,10551741,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 400CC,10551741,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 440CC,10551742,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 440CC,10551742,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 490CC,10551743,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 490CC,10551743,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 540CC,10551744,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 540CC,10551744,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 590CC,10551745,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 590CC,10551745,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSLP 640CC,10551746,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSLP 640CC,10551746,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY 4F STR 100CM X_31-527 X_BOSTON SC,10551748,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY 4F 65CM X_31-609 X_BOSTON SCIENTI,10551749,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY 4F 100CM X_31-633 X_BOSTON SCIENT,10551750,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY 4F 65CM X_31-663 X_BOSTON SCIENTI,10551751,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY 4F 65CM X_31-667 X_BOSTON SCIENTI,10551752,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,71.00,21.30,30.18,60.35,,43.88,,,percent of total billed charges,,,,,,,,service not payable,34.65,,,percent of total billed charges,,,35.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,53.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.5,,,percent of total billed charges,,,,,,,,service not payable,53.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,32.66,,,percent of total billed charges,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,46.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Remove tunneled CVA device w/subcut port/pump ce,10551770,CDM,0450,RC,36590,CPT,,,,,,outpatient,facility,,,2765.00,829.50,774.0,2350.25,,1708.77,,,percent of total billed charges,,,,,,,,,1349.32,,,percent of total billed charges,,,1394.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2073.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2073.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2350.25,,,percent of total billed charges,,,1271.90,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Remove tunneled CVA device w/subcut port/pump ce,10551770,CDM,0450,RC,36590,CPT,05182,APC,,,,outpatient,facility,,,2765.00,829.50,714.45,3421.46,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3133.81,,,fee schedule,,,714.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",1519.49,,,fee schedule,,,3421.46,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,3088.40,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,714.45,,,fee schedule,,,1519.49,,,fee schedule,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,714.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",1519.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,,,,,,,1489.7,,,fee schedule,,,,,,,,,1504.53,,,fee schedule,,,,,,,,
Remove tunneled CVA device w/subcut port/pump ce,10551770,CDM,0450,RC,36590,CPT,76,EAPG,,,,outpatient,facility,,,2765.00,829.50,1072.29,4867.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4867.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4137.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1072.29,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1072.29,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1072.29,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1454.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1599.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
RF Guide Ablat Vein,10551778,CDM,0490,RC,36475,CPT,,,,,,outpatient,facility,,,11546.00,3463.80,4700.0,9814.10,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,5823.80,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9814.10,,,percent of total billed charges,,,5311.16,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
RF Guide Ablat Vein,10551778,CDM,0490,RC,36475,CPT,05183,APC,,,,outpatient,facility,,,11546.00,3463.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
RF Guide Ablat Vein,10551778,CDM,0490,RC,36475,CPT,103,EAPG,,,,outpatient,facility,,,11546.00,3463.80,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
RF Guide Ablat Addl Vein,10551780,CDM,0490,RC,36476,CPT,,,,,,outpatient,facility,,,5770.00,1731.00,1106.0,4904.5,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,2910.39,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RF Guide Ablat Addl Vein,10551780,CDM,0490,RC,36476,CPT,103,EAPG,,,,outpatient,facility,,,5770.00,1731.00,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Endovenous Ablat Vein,10551782,CDM,0490,RC,36478,CPT,,,,,,outpatient,facility,,,11546.00,3463.80,4700.0,9814.10,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,5823.80,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9814.10,,,percent of total billed charges,,,5311.16,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Endovenous Ablat Vein,10551782,CDM,0490,RC,36478,CPT,05183,APC,,,,outpatient,facility,,,11546.00,3463.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Endovenous Ablat Vein,10551782,CDM,0490,RC,36478,CPT,103,EAPG,,,,outpatient,facility,,,11546.00,3463.80,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
RF Guide Ablat Vein,10551783,CDM,0490,RC,36475,CPT,,,,,,outpatient,facility,,,11546.00,3463.80,4700.0,9814.10,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,5823.80,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9814.10,,,percent of total billed charges,,,5311.16,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
RF Guide Ablat Vein,10551783,CDM,0490,RC,36475,CPT,05183,APC,,,,outpatient,facility,,,11546.00,3463.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
RF Guide Ablat Vein,10551783,CDM,0490,RC,36475,CPT,103,EAPG,,,,outpatient,facility,,,11546.00,3463.80,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
RF Guide Ablat Addl Vein,10551784,CDM,0490,RC,36476,CPT,,,,,,outpatient,facility,,,5770.00,1731.00,1106.0,4904.5,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,2910.39,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RF Guide Ablat Addl Vein,10551784,CDM,0490,RC,36476,CPT,103,EAPG,,,,outpatient,facility,,,5770.00,1731.00,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Endovenous Ablat Vein,10551785,CDM,0490,RC,36478,CPT,,,,,,outpatient,facility,,,11546.00,3463.80,4700.0,9814.10,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,5823.80,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,8659.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9814.10,,,percent of total billed charges,,,5311.16,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Endovenous Ablat Vein,10551785,CDM,0490,RC,36478,CPT,05183,APC,,,,outpatient,facility,,,11546.00,3463.80,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Endovenous Ablat Vein,10551785,CDM,0490,RC,36478,CPT,103,EAPG,,,,outpatient,facility,,,11546.00,3463.80,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
DELIV SYS 6F 45D 60CM TIP,10552704,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DELIV SYS 6F 45D 60CM TIP,10552704,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DELIV SYS 7F 45D 60CM TIP,10552705,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DELIV SYS 7F 45D 60CM TIP,10552705,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DELIV SYS 7F 45D 80CM TIP,10552706,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DELIV SYS 7F 45D 80CM TIP,10552706,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DELIV SYS 8F 45D 60CM TIP,10552707,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DELIV SYS 8F 45D 60CM TIP,10552707,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DELIV SYS 10F 45D 80CM TIP,10552708,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DELIV SYS 10F 45D 80CM TIP,10552708,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DELIV SYS 12F 45D 80CM TIP,10552709,CDM,0278,RC,C1893,HCPCS,,,,,,inpatient,facility,,,3580.00,1074.00,1389.04,3043.0,,,,,,,,,,,,,,,,,,,,1389.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3043.0,,,percent of total billed charges,,,1611.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DELIV SYS 12F 45D 80CM TIP,10552709,CDM,0278,RC,C1893,HCPCS,,,,,,outpatient,facility,,,3580.00,1074.00,1521.5,3043.0,,,,,,,,,,,,,service not payable,,,,,,,1805.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1521.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2685.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1790.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3043.0,,,percent of total billed charges,,,1646.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
REFLEX ONLY F tularensis Antibodies by Agglutinati,10552776,CDM,0300,RC,86000,CPT,,,,,,outpatient,facility,,,41.00,12.30,6.63,34.85,,16.18,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.84,,,fee schedule,,,12.07,,,fee schedule,,,14.56,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,14.45,,,fee schedule,,,6.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.98,,,fee schedule,,,15.77,,,fee schedule,,,,,,,,,6.84,,,fee schedule,,,,,,,,,8.85,,,fee schedule,,,14.24,,,fee schedule,,,30.75,,,percent of total billed charges,,,6.84,,,fee schedule,,,6.63,,,fee schedule,,,6.98,,,fee schedule,,,10.41,,,fee schedule,,,6.84,,,fee schedule,,,30.75,,,percent of total billed charges,,,,,,,,,6.98,,,fee schedule,,,,,,,,,34.85,,,percent of total billed charges,,,18.86,,,percent of total billed charges,,,,,,,,,7.68,,,fee schedule,,,6.84,,,fee schedule,,,,,,,,,6.77,,,fee schedule,,,6.84,,,fee schedule,,,,,,,,,6.91,,,fee schedule,,,,,,,,
REFLEX ONLY F tularensis Antibodies by Agglutinati,10552776,CDM,0300,RC,86000,CPT,394,EAPG,,,,outpatient,facility,,,41.00,12.30,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Calprotectin Fecal (3002859),10552783,CDM,0300,RC,83993,CPT,,,,,,outpatient,facility,,,128.00,38.40,18.65,108.8,,83.40,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,19.24,,,fee schedule,,,62.23,,,fee schedule,,,40.93,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,40.63,,,fee schedule,,,18.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",19.62,,,fee schedule,,,44.36,,,fee schedule,,,,,,,,,19.24,,,fee schedule,,,,,,,,,25.28,,,fee schedule,,,40.05,,,fee schedule,,,96.0,,,percent of total billed charges,,,19.24,,,fee schedule,,,18.65,,,fee schedule,,,19.62,,,fee schedule,,,29.73,,,fee schedule,,,19.24,,,fee schedule,,,96.0,,,percent of total billed charges,,,,,,,,,19.62,,,fee schedule,,,,,,,,,108.8,,,percent of total billed charges,,,58.88,,,percent of total billed charges,,,,,,,,,21.59,,,fee schedule,,,19.24,,,fee schedule,,,,,,,,,19.04,,,fee schedule,,,19.24,,,fee schedule,,,,,,,,,19.43,,,fee schedule,,,,,,,,
Calprotectin Fecal (3002859),10552783,CDM,0300,RC,83993,CPT,400,EAPG,,,,outpatient,facility,,,128.00,38.40,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chromogranin A (3002867),10552794,CDM,0300,RC,86316,CPT,,,,,,outpatient,facility,,,87.00,26.10,19.77,87.0,,87.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,20.39,,,fee schedule,,,65.99,,,fee schedule,,,43.40,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,43.08,,,fee schedule,,,19.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",20.80,,,fee schedule,,,47.03,,,fee schedule,,,,,,,,,20.39,,,fee schedule,,,,,,,,,26.97,,,fee schedule,,,42.45,,,fee schedule,,,65.25,,,percent of total billed charges,,,20.39,,,fee schedule,,,19.77,,,fee schedule,,,20.80,,,fee schedule,,,31.71,,,fee schedule,,,20.39,,,fee schedule,,,65.25,,,percent of total billed charges,,,,,,,,,20.80,,,fee schedule,,,,,,,,,73.95,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,,,,,,,22.89,,,fee schedule,,,20.39,,,fee schedule,,,,,,,,,20.19,,,fee schedule,,,20.39,,,fee schedule,,,,,,,,,20.60,,,fee schedule,,,,,,,,
Chromogranin A (3002867),10552794,CDM,0300,RC,86316,CPT,394,EAPG,,,,outpatient,facility,,,87.00,26.10,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PMC-Fluoro Guidance for Needle Placement,10552825,CDM,0320,RC,77002,CPT,,,,,,outpatient,facility,,,1180.00,354.00,136.37,1003.0,,182.77,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA RAD PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,service not payable,136.37,,,fee schedule,,,595.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,501.5,,,percent of total billed charges,,,,,,,,,885.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,590.0,,,percent of total billed charges,,,,,,,,service not payable,885.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1003.0,,,percent of total billed charges,,,542.80,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PMC-Fluoro Guidance for Needle Placement,10552825,CDM,0320,RC,77002,CPT,474,EAPG,,,,outpatient,facility,,,1180.00,354.00,294.16,697.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,592.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,294.16,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,436.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,480.13,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LINER ACETABULAR 0D 40X62MM,10553064,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 0D 40X62MM,10553064,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 SZ6 11MM,10553065,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 SZ6 11MM,10553065,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L RT XL 3X3,10553066,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,870.00,261.00,337.56,739.5,,,,,,,,,,,,,,,,,,,,337.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,652.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,435.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L RT XL 3X3,10553066,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,870.00,261.00,369.75,739.5,,,,,,,,,,,,,service not payable,,,,,,,438.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,369.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,652.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,435.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,652.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,739.5,,,percent of total billed charges,,,400.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE L LT XL 3X3,10553067,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,870.00,261.00,337.56,739.5,,,,,,,,,,,,,,,,,,,,337.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,652.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,435.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE L LT XL 3X3,10553067,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,870.00,261.00,369.75,739.5,,,,,,,,,,,,,service not payable,,,,,,,438.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,369.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,652.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,435.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,652.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,739.5,,,percent of total billed charges,,,400.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE X DRIVE 1.5 X 7.0MM,10553068,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE X DRIVE 1.5 X 7.0MM,10553068,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE X DRIVE 1.5 X 9.0MM,10553069,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,384.00,115.20,148.99,326.40,,,,,,,,,,,,,,,,,,,,148.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,172.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE X DRIVE 1.5 X 9.0MM,10553069,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,,,,,,,,,,,,service not payable,,,,,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MATRIX 1.5 2X3,10553072,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1525.00,457.50,591.70,1296.25,,,,,,,,,,,,,,,,,,,,591.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1143.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.25,,,percent of total billed charges,,,686.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MATRIX 1.5 2X3,10553072,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1525.00,457.50,648.12,1296.25,,,,,,,,,,,,,service not payable,,,,,,,769.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,648.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1143.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1143.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1296.25,,,percent of total billed charges,,,701.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MATRIX 1.5 2X4,10553073,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1525.00,457.50,591.70,1296.25,,,,,,,,,,,,,,,,,,,,591.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1143.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,762.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.25,,,percent of total billed charges,,,686.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MATRIX 1.5 2X4,10553073,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1525.00,457.50,648.12,1296.25,,,,,,,,,,,,,service not payable,,,,,,,769.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,648.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1143.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,762.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1143.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1296.25,,,percent of total billed charges,,,701.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW X-DR 2.0X11MM,10553074,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,404.00,121.20,156.75,343.40,,,,,,,,,,,,,,,,,,,,156.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.40,,,percent of total billed charges,,,181.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW X-DR 2.0X11MM,10553074,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,404.00,121.20,171.70,343.40,,,,,,,,,,,,,service not payable,,,,,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,303.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW X-DR 2.0X13MM,10553075,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,404.00,121.20,156.75,343.40,,,,,,,,,,,,,,,,,,,,156.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.40,,,percent of total billed charges,,,181.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW X-DR 2.0X13MM,10553075,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,404.00,121.20,171.70,343.40,,,,,,,,,,,,,service not payable,,,,,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,303.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB MODULAR FINNED 40MM,10553079,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB MODULAR FINNED 40MM,10553079,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL LOCKING BAR 67MM,10553080,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL LOCKING BAR 67MM,10553080,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM STEM RT 62.5IN,10553081,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11227.00,3368.10,4356.08,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4356.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9542.95,,,percent of total billed charges,,,5052.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM STEM RT 62.5IN,10553081,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11227.00,3368.10,4715.34,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5662.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9542.95,,,percent of total billed charges,,,5164.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO 15X155MM,10553082,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO 15X155MM,10553082,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HIV-1/2 Ag/Ab Combo - MH/WH/JE,10553159,CDM,0300,RC,G0475,HCPCS,,,,,,outpatient,facility,,,84.00,25.20,23.36,71.40,,51.91,,,percent of total billed charges,,,23.60,,,fee schedule,,,41.33,,,fee schedule,,,50.22,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,49.85,,,fee schedule,,,,,,,,service not payable,24.07,,,fee schedule,,,54.42,,,fee schedule,,,,,,,,,23.60,,,fee schedule,,,,,,,,,31.17,,,fee schedule,,,49.12,,,fee schedule,,,63.0,,,percent of total billed charges,,,23.60,,,fee schedule,,,,,,,,service not payable,24.07,,,fee schedule,,,36.66,,,fee schedule,,,23.60,,,fee schedule,,,63.0,,,percent of total billed charges,,,,,,,,service not payable,24.07,,,fee schedule,,,,,,,,,71.40,,,percent of total billed charges,,,38.64,,,percent of total billed charges,,,,,,,,,26.49,,,fee schedule,,,23.60,,,fee schedule,,,,,,,,,23.36,,,fee schedule,,,23.60,,,fee schedule,,,,,,,,,23.83,,,fee schedule,,,,,,,,
HIV-1/2 Ag/Ab Combo - MH/WH/JE,10553159,CDM,0300,RC,G0475,HCPCS,394,EAPG,,,,outpatient,facility,,,84.00,25.20,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
HIV-1/2 Ag/Ab Combo - MH/WH/JE,10553159,CDM,0300,RC,87389,CPT,,,,,,outpatient,facility,,,75.00,22.50,22.88,75.0,,75.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,23.60,,,fee schedule,,,75.0,,,fee schedule,,,50.22,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,49.85,,,fee schedule,,,22.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",24.07,,,fee schedule,,,54.42,,,fee schedule,,,,,,,,,23.60,,,fee schedule,,,,,,,,,31.17,,,fee schedule,,,49.12,,,fee schedule,,,56.25,,,percent of total billed charges,,,23.60,,,fee schedule,,,22.88,,,fee schedule,,,24.07,,,fee schedule,,,36.66,,,fee schedule,,,23.60,,,fee schedule,,,56.25,,,percent of total billed charges,,,,,,,,,24.07,,,fee schedule,,,,,,,,,63.75,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,,,,,,,26.49,,,fee schedule,,,23.60,,,fee schedule,,,,,,,,,23.36,,,fee schedule,,,23.60,,,fee schedule,,,,,,,,,23.83,,,fee schedule,,,,,,,,
HIV-1/2 Ag/Ab Combo - MH/WH/JE,10553159,CDM,0300,RC,87389,CPT,396,EAPG,,,,outpatient,facility,,,75.00,22.50,12.47,41.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,35.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.47,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,28.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,31.37,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STEM HUM PTC STD FLEX SZ8B,10553267,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2732.00,819.60,1060.02,2322.20,,,,,,,,,,,,,,,,,,,,1060.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322.20,,,percent of total billed charges,,,1229.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM PTC STD FLEX SZ8B,10553267,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2732.00,819.60,1161.10,2322.20,,,,,,,,,,,,,service not payable,,,,,,,1378.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1161.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2049.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1366.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2049.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2322.20,,,percent of total billed charges,,,1256.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1/3 TUBULAR 10H 121MM,10553269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1/3 TUBULAR 10H 121MM,10553269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 26MM,10553270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 26MM,10553270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 28MM,10553271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 28MM,10553271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 40MM,10553272,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 40MM,10553272,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 38MM,10553273,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 38MM,10553273,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB MEDI DIST 12H 162MM,10553274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6748.00,2024.40,2618.22,5735.80,,3306.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2834.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2618.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2867.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5061.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3374.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5735.80,,,percent of total billed charges,,,3036.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB MEDI DIST 12H 162MM,10553274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6748.00,2024.40,2834.16,5735.80,,3306.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2834.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3403.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2867.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5061.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3374.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5061.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5735.80,,,percent of total billed charges,,,3104.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX15MM CT,10553276,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX15MM CT,10553276,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE EVOS 3.5MMX17MM CT,10553277,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,163.00,48.90,63.24,138.55,,,,,,,,,,,,,,,,,,,,63.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.55,,,percent of total billed charges,,,73.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE EVOS 3.5MMX17MM CT,10553277,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,163.00,48.90,69.27,138.55,,,,,,,,,,,,,service not payable,,,,,,,82.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,122.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,81.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,122.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,138.55,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT SHOULDER REV 42X9X12.5,10553435,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT SHOULDER REV 42X9X12.5,10553435,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASEPLATE LAT REV 3MM 29MM,10553436,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASEPLATE LAT REV 3MM 29MM,10553436,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 24.5,10553439,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 24.5,10553439,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 7.5,10553440,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 7.5,10553440,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ENDOVENT PULM 8.3F 60CM,10553622,CDM,0272,RC,C1729,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2438.65,4877.30,,3546.08,,,percent of total billed charges,,,,,,,,service not payable,2800.14,,,percent of total billed charges,,,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3729.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE KIT INTUITY 19MM,10553623,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26226.00,7867.80,10175.69,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10175.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22292.10,,,percent of total billed charges,,,11801.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE KIT INTUITY 19MM,10553623,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26226.00,7867.80,11014.92,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13228.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22292.10,,,percent of total billed charges,,,12063.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE KIT INTUITY 21MM,10553624,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26226.00,7867.80,10175.69,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10175.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22292.10,,,percent of total billed charges,,,11801.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE KIT INTUITY 21MM,10553624,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26226.00,7867.80,11014.92,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13228.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22292.10,,,percent of total billed charges,,,12063.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE KIT INTUITY 23MM,10553625,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26226.00,7867.80,10175.69,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10175.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22292.10,,,percent of total billed charges,,,11801.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE KIT INTUITY 23MM,10553625,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26226.00,7867.80,11014.92,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13228.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22292.10,,,percent of total billed charges,,,12063.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE KIT INTUITY 25MM,10553626,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26226.00,7867.80,10175.69,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10175.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22292.10,,,percent of total billed charges,,,11801.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE KIT INTUITY 25MM,10553626,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26226.00,7867.80,11014.92,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13228.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22292.10,,,percent of total billed charges,,,12063.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE KIT INTUITY 27MM,10553627,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26226.00,7867.80,10175.69,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10175.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22292.10,,,percent of total billed charges,,,11801.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE KIT INTUITY 27MM,10553627,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26226.00,7867.80,11014.92,22292.10,,12850.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11014.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13228.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13113.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19669.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22292.10,,,percent of total billed charges,,,12063.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OSC 10CC OSSIFLEX FILLER,10553629,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4337.00,1301.10,1682.76,3686.45,,,,,,,,,,,,,,,,,,,,1682.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1843.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3252.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2168.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3686.45,,,percent of total billed charges,,,1951.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSC 10CC OSSIFLEX FILLER,10553629,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4337.00,1301.10,1843.22,3686.45,,,,,,,,,,,,,service not payable,,,,,,,2187.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1843.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3252.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2168.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3252.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3686.45,,,percent of total billed charges,,,1995.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC NCB PROT 70X5MM,10553630,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC NCB PROT 70X5MM,10553630,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NCB ST 5.0X10MM,10553631,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,738.00,221.40,286.34,627.30,,,,,,,,,,,,,,,,,,,,286.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,332.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NCB ST 5.0X10MM,10553631,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,,,,,,,,,,,,service not payable,,,,,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE RT 10-11 12MM,10553632,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE RT 10-11 12MM,10553632,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING PSN 12MM RT SZ10-12,10553633,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING PSN 12MM RT SZ10-12,10553633,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM RT MEDIAL SZ 5,10553634,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5083.00,1524.90,1972.20,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1972.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4320.55,,,percent of total billed charges,,,2287.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM RT MEDIAL SZ 5,10553634,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2134.86,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB RT MEDIAL SZ E,10553635,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB RT MEDIAL SZ E,10553635,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB MEDI RT SZ E 8MM,10553636,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB MEDI RT SZ E 8MM,10553636,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE CEM LT 5D SZ F,10553637,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE CEM LT 5D SZ F,10553637,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA KNEE CEMENTED 38X9.5MM,10553638,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE CEMENTED 38X9.5MM,10553638,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR II 36X52MM,10553639,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR II 36X52MM,10553639,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12-14 TPR 7.5X114MM,10553640,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12-14 TPR 7.5X114MM,10553640,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X44MM,10553641,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X44MM,10553641,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIS NCB LT 12H 278MM,10553642,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3984.00,1195.20,1545.79,3386.40,,,,,,,,,,,,,,,,,,,,1545.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2988.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1992.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3386.40,,,percent of total billed charges,,,1792.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIS NCB LT 12H 278MM,10553642,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3984.00,1195.20,1693.2,3386.40,,,,,,,,,,,,,service not payable,,,,,,,2009.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1693.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2988.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1992.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2988.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3386.40,,,percent of total billed charges,,,1832.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CANCELLOUS 5 X 50MM,10553643,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CANCELLOUS 5 X 50MM,10553643,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 3.5X50MM,10553644,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 3.5X50MM,10553644,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI LOCKING 3.5X48MM,10553645,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI LOCKING 3.5X48MM,10553645,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI LOCKING 3.5X50MM,10553646,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI LOCKING 3.5X50MM,10553646,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN STEIMANN 1.5MMX60CM,10554185,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN STEIMANN 1.5MMX60CM,10554185,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS UV TORIC ASPHERIC 18.5D,10554190,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS UV TORIC ASPHERIC 18.5D,10554190,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT MRI 2.16MM 28CM,10554194,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,12703.00,3810.90,4928.76,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4928.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10797.55,,,percent of total billed charges,,,5716.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT MRI 2.16MM 28CM,10554194,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,12703.00,3810.90,5335.26,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6407.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10797.55,,,percent of total billed charges,,,5843.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT MRI 2.16MM 33CM,10554195,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,12703.00,3810.90,4928.76,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4928.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10797.55,,,percent of total billed charges,,,5716.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT MRI 2.16MM 33CM,10554195,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,12703.00,3810.90,5335.26,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6407.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10797.55,,,percent of total billed charges,,,5843.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT MRI 2.16MM 41CM,10554196,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,12703.00,3810.90,4928.76,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4928.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10797.55,,,percent of total billed charges,,,5716.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT MRI 2.16MM 41CM,10554196,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,12703.00,3810.90,5335.26,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6407.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10797.55,,,percent of total billed charges,,,5843.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT MRI 4.32MM 28CM,10554197,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,12703.00,3810.90,4928.76,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4928.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10797.55,,,percent of total billed charges,,,5716.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT MRI 4.32MM 28CM,10554197,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,12703.00,3810.90,5335.26,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6407.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10797.55,,,percent of total billed charges,,,5843.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT MRI 4.32MM 33CM,10554198,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,12703.00,3810.90,4928.76,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4928.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10797.55,,,percent of total billed charges,,,5716.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT MRI 4.32MM 33CM,10554198,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,12703.00,3810.90,5335.26,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6407.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10797.55,,,percent of total billed charges,,,5843.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD KIT MRI 4.32MM 41CM,10554199,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,12703.00,3810.90,4928.76,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4928.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10797.55,,,percent of total billed charges,,,5716.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD KIT MRI 4.32MM 41CM,10554199,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,12703.00,3810.90,5335.26,10797.55,,6224.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5335.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6407.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5398.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9527.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6351.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9527.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10797.55,,,percent of total billed charges,,,5843.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT PROGRAMMER INTERSTIM COMM TH90P01,10554202,CDM,0278,RC,C1787,HCPCS,,,,,,inpatient,facility,,,6394.00,1918.20,2480.87,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.90,,,percent of total billed charges,,,2877.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT PROGRAMMER INTERSTIM COMM TH90P01,10554202,CDM,0278,RC,C1787,HCPCS,,,,,,outpatient,facility,,,6394.00,1918.20,2685.48,5434.90,,3133.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3225.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4795.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4795.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.90,,,percent of total billed charges,,,2941.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HAND 1.7 2X2H,10554203,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2332.00,699.60,904.82,1982.2,,,,,,,,,,,,,,,,,,,,904.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,991.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1749.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1166.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1982.2,,,percent of total billed charges,,,1049.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HAND 1.7 2X2H,10554203,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2332.00,699.60,991.10,1982.2,,,,,,,,,,,,,service not payable,,,,,,,1176.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,991.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1749.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1166.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1749.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1982.2,,,percent of total billed charges,,,1072.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T5 1.7X5MM,10554204,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1017.00,305.10,394.60,864.45,,,,,,,,,,,,,,,,,,,,394.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.45,,,percent of total billed charges,,,457.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T5 1.7X5MM,10554204,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.22,864.45,,,,,,,,,,,,,service not payable,,,,,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T5 1.7X7MM,10554205,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1017.00,305.10,394.60,864.45,,,,,,,,,,,,,,,,,,,,394.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.45,,,percent of total billed charges,,,457.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T5 1.7X7MM,10554205,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.22,864.45,,,,,,,,,,,,,service not payable,,,,,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T5 1.7X9MM,10554206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1017.00,305.10,394.60,864.45,,,,,,,,,,,,,,,,,,,,394.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.45,,,percent of total billed charges,,,457.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T5 1.7X9MM,10554206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.22,864.45,,,,,,,,,,,,,service not payable,,,,,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T5 1.7X10MM,10554207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1017.00,305.10,394.60,864.45,,,,,,,,,,,,,,,,,,,,394.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.45,,,percent of total billed charges,,,457.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T5 1.7X10MM,10554207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.22,864.45,,,,,,,,,,,,,service not payable,,,,,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER BI -MENTUM PE 28/59,10554208,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER BI -MENTUM PE 28/59,10554208,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP PRESSFIT BI-MENTUM 55MM,10554209,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP PRESSFIT BI-MENTUM 55MM,10554209,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER BI -MENTUM PE 28/55,10554210,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER BI -MENTUM PE 28/55,10554210,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM ATT PRESSFIT REV 12X60MM,10554211,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM ATT PRESSFIT REV 12X60MM,10554211,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REV KNEE CRS RP SZ 6 12,10554212,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV KNEE CRS RP SZ 6 12,10554212,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP PRESSFIT BI-MENTUM 59MM,10554896,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP PRESSFIT BI-MENTUM 59MM,10554896,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Biopsy of anorectal wall anal approach,10554988,CDM,0750,RC,45100,CPT,,,,,,outpatient,facility,,,7322.00,2196.60,1972.0,6223.70,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,3693.22,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,5491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,5491.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6223.70,,,percent of total billed charges,,,3368.12,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Biopsy of anorectal wall anal approach,10554988,CDM,0750,RC,45100,CPT,05313,APC,,,,outpatient,facility,,,7322.00,2196.60,2522.53,6040.12,,,,,,,,2629.86,,,fee schedule,,,,,,,,,,,,,,,5532.32,,,fee schedule,,,2522.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2682.46,,,fee schedule,,,6040.12,,,fee schedule,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,,,,,,,5452.14,,,fee schedule,,,,,,,,,2629.86,,,fee schedule,,,2522.53,,,fee schedule,,,2682.46,,,fee schedule,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,2522.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2682.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,,,,,,,2629.86,,,fee schedule,,,,,,,,,2656.05,,,fee schedule,,,,,,,,
END-Biopsy of anorectal wall anal approach,10554988,CDM,0750,RC,45100,CPT,141,EAPG,,,,outpatient,facility,,,7322.00,2196.60,2092.24,5987.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5987.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5089.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2092.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3000.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3300.20,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WALKER CAM BOOT TD AIR STD SM X_TDA-SM X_341485,10554997,CDM,0274,RC,L4361,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WALKER CAM BOOT TD AIR STD SM X_TDA-SM X_341485,10554997,CDM,0274,RC,L4361,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,370.64,,,,,,,,161.38,,,fee schedule,,,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,339.48,,,fee schedule,,,164.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",164.61,,,fee schedule,,,370.64,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,334.56,,,fee schedule,,,123.0,,,percent of total billed charges,,,161.38,,,fee schedule,,,164.0,,,fee schedule,,,164.61,,,fee schedule,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,161.38,,,fee schedule,,,123.0,,,percent of total billed charges,,,164.0,,,fee schedule,,,164.61,,,fee schedule,,,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,,,,,,,161.38,,,fee schedule,,,,,,,,,161.38,,,fee schedule,,,,,,,,
COMPONENT FEM SZ D LT 3-5X12MM,10555003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ D LT 3-5X12MM,10555003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ E LT 4-6X12MM,10555004,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ E LT 4-6X12MM,10555004,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV CONS 1 LVL 28MM,10555006,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2841.00,852.30,1102.31,2414.85,,,,,,,,,,,,,,,,,,,,1102.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2414.85,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV CONS 1 LVL 28MM,10555006,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2841.00,852.30,1207.42,2414.85,,,,,,,,,,,,,service not payable,,,,,,,1433.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1207.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2130.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2130.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2414.85,,,percent of total billed charges,,,1306.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE XS 3CM STR TIP 180CM,10555007,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,321.00,96.30,136.43,272.85,,198.38,,,percent of total billed charges,,,,,,,,service not payable,156.65,,,percent of total billed charges,,,161.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.43,,,percent of total billed charges,,,,,,,,,240.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.5,,,percent of total billed charges,,,,,,,,service not payable,240.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.85,,,percent of total billed charges,,,147.66,,,percent of total billed charges,,,,,,,,,208.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,208.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE XS STR TIP 300CM,10555008,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,321.00,96.30,136.43,272.85,,198.38,,,percent of total billed charges,,,,,,,,service not payable,156.65,,,percent of total billed charges,,,161.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.43,,,percent of total billed charges,,,,,,,,,240.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.5,,,percent of total billed charges,,,,,,,,service not payable,240.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.85,,,percent of total billed charges,,,147.66,,,percent of total billed charges,,,,,,,,,208.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,208.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DCB 6X80MM 130CM,10555009,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1.7MM Y-NRW 7H,10555234,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1262.00,378.60,489.66,1072.7,,,,,,,,,,,,,,,,,,,,489.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,946.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,631.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1072.7,,,percent of total billed charges,,,567.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1.7MM Y-NRW 7H,10555234,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1262.00,378.60,536.35,1072.7,,,,,,,,,,,,,service not payable,,,,,,,636.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,536.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,946.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,631.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,946.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1072.7,,,percent of total billed charges,,,580.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATO 5.0X40,10555235,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATO 5.0X40,10555235,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SM R-R,10555236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2483.00,744.90,963.40,2110.55,,,,,,,,,,,,,,,,,,,,963.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1055.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1862.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1241.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2110.55,,,percent of total billed charges,,,1117.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SM R-R,10555236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2483.00,744.90,1055.27,2110.55,,,,,,,,,,,,,service not payable,,,,,,,1252.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1055.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1862.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1241.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1862.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2110.55,,,percent of total billed charges,,,1142.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SERRATP 7.5X55,10555237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SERRATP 7.5X55,10555237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA STEM 5 DEG SZF RT,10555238,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA STEM 5 DEG SZF RT,10555238,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR STD SZ9 RT,10555239,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23357.00,7007.10,9062.52,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9062.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19853.45,,,percent of total billed charges,,,10510.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR STD SZ9 RT,10555239,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23357.00,7007.10,9809.94,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11781.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19853.45,,,percent of total billed charges,,,10744.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART 10MM RT,10555240,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART 10MM RT,10555240,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART FEM RT 6-9 CD 13MM,10555243,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART FEM RT 6-9 CD 13MM,10555243,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP LPS MOBILE D 3- 5 12MM,10555245,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP LPS MOBILE D 3- 5 12MM,10555245,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS-FLEX GSF RT SZ D,10555246,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS-FLEX GSF RT SZ D,10555246,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB PS 12MM 63/67MM,10555247,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB PS 12MM 63/67MM,10555247,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM POST SZ 7 7 5MM,10555248,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM POST SZ 7 7 5MM,10555248,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING FIXED 20MM RIGHT,10555249,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING FIXED 20MM RIGHT,10555249,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXTENSION 11MM 6MM 135MM,10555250,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXTENSION 11MM 6MM 135MM,10555250,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT RT LATERAL 10MM,10555251,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT RT LATERAL 10MM,10555251,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL DISTAL AUGMNT 7 7 5MM,10555252,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL DISTAL AUGMNT 7 7 5MM,10555252,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP STD WRIST 118MM,10555253,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7900.00,2370.00,3065.20,6715.0,,3871.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3318.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3065.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3357.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5925.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3950.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6715.0,,,percent of total billed charges,,,3555.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP STD WRIST 118MM,10555253,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7900.00,2370.00,3318.0,6715.0,,3871.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3318.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3984.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3357.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5925.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3950.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5925.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6715.0,,,percent of total billed charges,,,3634.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEEDLES VITOSS BONE MAR 11GX4,10555255,CDM,0272,RC,A4649,HCPCS,,,,,,outpatient,facility,,,10524.00,3157.20,4472.70,8945.40,,6503.83,,,percent of total billed charges,,,,,,,,service not payable,5135.71,,,percent of total billed charges,,,5308.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4472.70,,,percent of total billed charges,,,,,,,,,7893.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,service not payable,7893.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8945.40,,,percent of total billed charges,,,4841.04,,,percent of total billed charges,,,,,,,,,6840.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,6840.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE XS J TIP 180CM,10555257,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,321.00,96.30,136.43,272.85,,198.38,,,percent of total billed charges,,,,,,,,service not payable,156.65,,,percent of total billed charges,,,161.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.43,,,percent of total billed charges,,,,,,,,,240.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.5,,,percent of total billed charges,,,,,,,,service not payable,240.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.85,,,percent of total billed charges,,,147.66,,,percent of total billed charges,,,,,,,,,208.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,208.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HDLSS 4.0X36MM,10555258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2708.00,812.40,1050.70,2301.80,,,,,,,,,,,,,,,,,,,,1050.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,,1218.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HDLSS 4.0X36MM,10555258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2708.00,812.40,1150.90,2301.80,,,,,,,,,,,,,service not payable,,,,,,,1365.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,,1245.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM IMPLANT ACUTE AC REPAIR,10555259,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5610.00,1683.00,2176.68,4768.5,,2748.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2356.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2176.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2384.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4207.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2805.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4768.5,,,percent of total billed charges,,,2524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM IMPLANT ACUTE AC REPAIR,10555259,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5610.00,1683.00,2356.20,4768.5,,2748.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2356.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2829.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2384.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4207.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2805.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4207.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4768.5,,,percent of total billed charges,,,2580.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP 3H RT LISFRANC,10555673,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP 3H RT LISFRANC,10555673,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FUSION 1.5MM/TH SM RT,10555675,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5498.00,1649.40,2133.22,4673.30,,2694.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2309.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2133.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2336.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2749.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4673.30,,,percent of total billed charges,,,2474.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FUSION 1.5MM/TH SM RT,10555675,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5498.00,1649.40,2309.16,4673.30,,2694.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2309.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2773.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2336.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2749.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4673.30,,,percent of total billed charges,,,2529.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X16MM R3CON,10555677,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X16MM R3CON,10555677,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X20MM R3CON,10555678,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X20MM R3CON,10555678,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT QFIX 1.8 MINI SUTURE ANCHO,10555679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3077.00,923.10,1193.88,2615.45,,,,,,,,,,,,,,,,,,,,1193.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1307.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2307.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1538.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2615.45,,,percent of total billed charges,,,1384.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT QFIX 1.8 MINI SUTURE ANCHO,10555679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3077.00,923.10,1307.72,2615.45,,,,,,,,,,,,,service not payable,,,,,,,1552.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1307.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2307.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1538.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2307.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2615.45,,,percent of total billed charges,,,1415.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP 3.5 8H 102MM,10555680,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1017.00,305.10,394.60,864.45,,,,,,,,,,,,,,,,,,,,394.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,864.45,,,percent of total billed charges,,,457.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP 3.5 8H 102MM,10555680,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1017.00,305.10,432.22,864.45,,,,,,,,,,,,,service not payable,,,,,,,512.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,432.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,762.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,762.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,864.45,,,percent of total billed charges,,,467.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THD 6.5MM 16X65MM,10555681,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1148.00,344.40,445.42,975.80,,,,,,,,,,,,,,,,,,,,445.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.80,,,percent of total billed charges,,,516.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THD 6.5MM 16X65MM,10555681,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1148.00,344.40,487.90,975.80,,,,,,,,,,,,,service not payable,,,,,,,579.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,861.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,574.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,861.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,975.80,,,percent of total billed charges,,,528.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP TI 3.5X13MM,10555682,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP TI 3.5X13MM,10555682,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAPTER TAPER MINI 25MM,10555683,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1804.00,541.20,699.95,1533.40,,,,,,,,,,,,,,,,,,,,699.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,902.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1533.40,,,percent of total billed charges,,,811.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADAPTER TAPER MINI 25MM,10555683,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1804.00,541.20,766.70,1533.40,,,,,,,,,,,,,service not payable,,,,,,,909.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,766.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1353.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,902.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1353.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1533.40,,,percent of total billed charges,,,829.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5 X 38MM R3CON,10555684,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5 X 38MM R3CON,10555684,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 2.7X20MM RSCON,10555685,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 2.7X20MM RSCON,10555685,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 3.5X30MM RSCON,10555686,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 3.5X30MM RSCON,10555686,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 3.5X32MM RSCON,10555687,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 3.5X32MM RSCON,10555687,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 3.5X36MM RSCON,10555688,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 3.5X36MM RSCON,10555688,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HDLS ST MM 4.0X40MM,10555689,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1492.00,447.60,578.90,1268.2,,,,,,,,,,,,,,,,,,,,578.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,634.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1119.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,746.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1268.2,,,percent of total billed charges,,,671.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HDLS ST MM 4.0X40MM,10555689,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1492.00,447.60,634.10,1268.2,,,,,,,,,,,,,service not payable,,,,,,,752.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,634.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1119.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,746.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1119.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1268.2,,,percent of total billed charges,,,686.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 45 X 3.5MM X_4206245 X_DEPUY SYNTHES,10556601,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,277.00,83.10,107.48,235.45,,,,,,,,,,,,,,,,,,,,107.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,207.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.45,,,percent of total billed charges,,,124.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 45 X 3.5MM X_4206245 X_DEPUY SYNTHES,10556601,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,277.00,83.10,117.72,235.45,,,,,,,,,,,,,service not payable,,,,,,,139.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,117.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,207.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,138.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,207.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,235.45,,,percent of total billed charges,,,127.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN ST THRD 7.3X75MM,10556603,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2029.00,608.70,787.25,1724.65,,,,,,,,,,,,,,,,,,,,787.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1521.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1014.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1724.65,,,percent of total billed charges,,,913.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN ST THRD 7.3X75MM,10556603,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2029.00,608.70,862.32,1724.65,,,,,,,,,,,,,service not payable,,,,,,,1023.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,862.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1521.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1521.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1724.65,,,percent of total billed charges,,,933.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN ST THRD 7.3X80MM,10556604,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2029.00,608.70,787.25,1724.65,,,,,,,,,,,,,,,,,,,,787.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1521.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1014.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1724.65,,,percent of total billed charges,,,913.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN ST THRD 7.3X80MM,10556604,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2029.00,608.70,862.32,1724.65,,,,,,,,,,,,,service not payable,,,,,,,1023.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,862.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1521.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1521.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1724.65,,,percent of total billed charges,,,933.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT FT 5.5X75MM,10556605,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT FT 5.5X75MM,10556605,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB MOMENTUM CRT-D IS-1 DF1,10556608,CDM,0278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,51358.00,15407.40,19926.90,43654.30,,25165.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21570.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,19926.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21827.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38518.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25679.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43654.30,,,percent of total billed charges,,,23111.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB MOMENTUM CRT-D IS-1 DF1,10556608,CDM,0278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,51358.00,15407.40,21570.36,43654.30,,25165.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21570.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,25904.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21827.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38518.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25679.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38518.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43654.30,,,percent of total billed charges,,,23624.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 4.5X24MM,10556612,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 4.5X24MM,10556612,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD YUKON CONTOURED 3.5X65MM,10556613,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD YUKON CONTOURED 3.5X65MM,10556613,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR RT SZ 10,10556614,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR RT SZ 10,10556614,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KN RT 10-11 EF 11MM,10556615,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KN RT 10-11 EF 11MM,10556615,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PRX HUM LO LT 7H 133MM,10556616,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6289.00,1886.70,2440.13,5345.65,,3081.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2641.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2440.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2672.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4716.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3144.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5345.65,,,percent of total billed charges,,,2830.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PRX HUM LO LT 7H 133MM,10556616,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6289.00,1886.70,2641.38,5345.65,,3081.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2641.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3172.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2672.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4716.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3144.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4716.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5345.65,,,percent of total billed charges,,,2892.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT VALVE TAVR COMMANDR 29MM,10556621,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT VALVE TAVR COMMANDR 29MM,10556621,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 25.0D,10556622,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 25.0D,10556622,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXTENSION 3MM 12X135MM,10556623,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXTENSION 3MM 12X135MM,10556623,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CMT SZ F R PERSONA,10556624,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CMT SZ F R PERSONA,10556624,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE TIB PERS REV SZ XS,10556625,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16801.00,5040.30,6518.79,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6518.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14280.85,,,percent of total billed charges,,,7560.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE TIB PERS REV SZ XS,10556625,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16801.00,5040.30,7056.42,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8474.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14280.85,,,percent of total billed charges,,,7728.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PERS RT SZ 7,10556626,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23357.00,7007.10,9062.52,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9062.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19853.45,,,percent of total billed charges,,,10510.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PERS RT SZ 7,10556626,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23357.00,7007.10,9809.94,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11781.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19853.45,,,percent of total billed charges,,,10744.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT HALF RM EF 10MM,10556627,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT HALF RM EF 10MM,10556627,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TENDON CONNECT PRESUTUR,10556628,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4007.00,1202.10,1554.72,3405.95,,,,,,,,,,,,,,,,,,,,1554.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1702.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3005.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2003.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3405.95,,,percent of total billed charges,,,1803.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TENDON CONNECT PRESUTUR,10556628,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4007.00,1202.10,1702.97,3405.95,,,,,,,,,,,,,service not payable,,,,,,,2021.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1702.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3005.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2003.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3005.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3405.95,,,percent of total billed charges,,,1843.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Gram Negative Blood Culture Molecular ID Panel,10556839,CDM,0300,RC,87154,CPT,,,,,,outpatient,facility,,,462.00,138.60,207.16,492.82,,285.52,,,percent of total billed charges,,,213.70,,,fee schedule,,,227.30,,,fee schedule,,,454.77,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,451.38,,,fee schedule,,,207.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",217.97,,,fee schedule,,,492.82,,,fee schedule,,,,,,,,,213.70,,,fee schedule,,,,,,,,,280.57,,,fee schedule,,,444.84,,,fee schedule,,,346.5,,,percent of total billed charges,,,213.70,,,fee schedule,,,207.16,,,fee schedule,,,217.97,,,fee schedule,,,329.97,,,fee schedule,,,213.70,,,fee schedule,,,346.5,,,percent of total billed charges,,,,,,,,,217.97,,,fee schedule,,,,,,,,,392.70,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,,,,,,,239.87,,,fee schedule,,,213.70,,,fee schedule,,,,,,,,,211.52,,,fee schedule,,,213.70,,,fee schedule,,,,,,,,,215.84,,,fee schedule,,,,,,,,
Gram Negative Blood Culture Molecular ID Panel,10556839,CDM,0300,RC,87154,CPT,388,EAPG,,,,outpatient,facility,,,462.00,138.60,202.12,322.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,273.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,202.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,222.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Gram Positive Blood Culture Molecular ID Panel,10556840,CDM,0300,RC,87154,CPT,,,,,,outpatient,facility,,,495.00,148.50,207.16,492.82,,305.91,,,percent of total billed charges,,,213.70,,,fee schedule,,,243.54,,,fee schedule,,,454.77,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,451.38,,,fee schedule,,,207.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",217.97,,,fee schedule,,,492.82,,,fee schedule,,,,,,,,,213.70,,,fee schedule,,,,,,,,,280.57,,,fee schedule,,,444.84,,,fee schedule,,,371.25,,,percent of total billed charges,,,213.70,,,fee schedule,,,207.16,,,fee schedule,,,217.97,,,fee schedule,,,329.97,,,fee schedule,,,213.70,,,fee schedule,,,371.25,,,percent of total billed charges,,,,,,,,,217.97,,,fee schedule,,,,,,,,,420.75,,,percent of total billed charges,,,227.70,,,percent of total billed charges,,,,,,,,,239.87,,,fee schedule,,,213.70,,,fee schedule,,,,,,,,,211.52,,,fee schedule,,,213.70,,,fee schedule,,,,,,,,,215.84,,,fee schedule,,,,,,,,
Gram Positive Blood Culture Molecular ID Panel,10556840,CDM,0300,RC,87154,CPT,388,EAPG,,,,outpatient,facility,,,495.00,148.50,202.12,322.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,273.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,240.71,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,202.12,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,222.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Excision soft tissue tumor back/flank subcut >/,10556993,CDM,0361,RC,21931,CPT,,,,,,outpatient,facility,,,4165.00,1249.50,1915.90,5076.0,,4165.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,2100.83,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,3123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,3123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3540.25,,,percent of total billed charges,,,1915.90,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Excision soft tissue tumor back/flank subcut >/,10556993,CDM,0361,RC,21931,CPT,05072,APC,,,,outpatient,facility,,,4165.00,1249.50,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
Excision soft tissue tumor back/flank subcut >/,10556993,CDM,0361,RC,21931,CPT,51,EAPG,,,,outpatient,facility,,,4165.00,1249.50,2603.45,6780.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6780.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5763.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2603.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2603.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2603.45,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2959.88,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3255.87,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COMP ARTIC KN RT 10-11 CD 13MM,10557145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KN RT 10-11 CD 13MM,10557145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STARDRIVE ST 3.5X45MM,10557147,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,277.00,83.10,107.48,235.45,,,,,,,,,,,,,,,,,,,,107.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,207.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.45,,,percent of total billed charges,,,124.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STARDRIVE ST 3.5X45MM,10557147,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,277.00,83.10,117.72,235.45,,,,,,,,,,,,,service not payable,,,,,,,139.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,117.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,207.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,138.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,207.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,235.45,,,percent of total billed charges,,,127.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ALLOPATCH HD THICK 1.7MM,10557148,CDM,0278,RC,Q4128,HCPCS,,,,,,inpatient,facility,,,5461.00,1638.30,2118.87,4641.85,,2675.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2293.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2118.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4095.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2730.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4641.85,,,percent of total billed charges,,,2457.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ALLOPATCH HD THICK 1.7MM,10557148,CDM,0278,RC,Q4128,HCPCS,,,,,,outpatient,facility,,,5461.00,1638.30,2293.62,4641.85,,2675.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2293.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2754.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2320.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4095.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2730.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4095.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4641.85,,,percent of total billed charges,,,2512.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ALLOPATCH HD THICK 1.7MM,10557148,CDM,0278,RC,Q4128,HCPCS,2010,EAPG,,,,outpatient,facility,,,5461.00,1638.30,24.47,30.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.47,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,24.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
NAIL BONE HFN LT 11.5MMX16CM,10557151,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6393.00,1917.90,2480.48,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2480.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5434.05,,,percent of total billed charges,,,2876.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL BONE HFN LT 11.5MMX16CM,10557151,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6393.00,1917.90,2685.06,5434.05,,3132.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2685.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3224.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2717.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4794.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3196.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4794.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5434.05,,,percent of total billed charges,,,2940.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X85MM,10557152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X85MM,10557152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LIFESTENT 5F 5 X 20MM X 130CM,10557153,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIFESTENT 5F 5 X 20MM X 130CM,10557153,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO SM XSFT 3MMX4CM,10557191,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3835.00,1150.50,1629.88,3259.75,,2370.03,,,percent of total billed charges,,,,,,,,service not payable,1871.48,,,percent of total billed charges,,,1934.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1629.88,,,percent of total billed charges,,,,,,,,,2876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1917.5,,,percent of total billed charges,,,,,,,,service not payable,2876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3259.75,,,percent of total billed charges,,,1764.10,,,percent of total billed charges,,,,,,,,,2492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO SM XSFT 2MMX4CM,10557192,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2452.25,4904.5,,3565.86,,,percent of total billed charges,,,,,,,,service not payable,2815.76,,,percent of total billed charges,,,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO XSFT 1.5MMX4CM,10557193,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2452.25,4904.5,,3565.86,,,percent of total billed charges,,,,,,,,service not payable,2815.76,,,percent of total billed charges,,,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO XSFT 2MMX4CM,10557194,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2452.25,4904.5,,3565.86,,,percent of total billed charges,,,,,,,,service not payable,2815.76,,,percent of total billed charges,,,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO XSFT 3MMX8CM,10557195,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2452.25,4904.5,,3565.86,,,percent of total billed charges,,,,,,,,service not payable,2815.76,,,percent of total billed charges,,,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO XSFT 1.5MMX3CM,10557196,CDM,0278,RC,C1884,HCPCS,,,,,,inpatient,facility,,,5770.00,1731.00,2238.76,4904.5,,2827.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2423.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2238.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2452.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2885.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4904.5,,,percent of total billed charges,,,2596.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COIL VASC EMBO XSFT 1.5MMX3CM,10557196,CDM,0278,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2423.40,4904.5,,2827.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2423.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO XSFT 3MMX4CM,10557197,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2452.25,4904.5,,3565.86,,,percent of total billed charges,,,,,,,,service not payable,2815.76,,,percent of total billed charges,,,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO XSFT 2.5MMX8CM,10557198,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,5770.00,1731.00,2452.25,4904.5,,3565.86,,,percent of total billed charges,,,,,,,,service not payable,2815.76,,,percent of total billed charges,,,2910.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2452.25,,,percent of total billed charges,,,,,,,,,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2885.0,,,percent of total billed charges,,,,,,,,service not payable,4327.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4904.5,,,percent of total billed charges,,,2654.20,,,percent of total billed charges,,,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3750.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COIL VASC EMBO HELICAL 2MMX6CM,10557199,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,3835.00,1150.50,1629.88,3259.75,,2370.03,,,percent of total billed charges,,,,,,,,service not payable,1871.48,,,percent of total billed charges,,,1934.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1629.88,,,percent of total billed charges,,,,,,,,,2876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1917.5,,,percent of total billed charges,,,,,,,,service not payable,2876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3259.75,,,percent of total billed charges,,,1764.10,,,percent of total billed charges,,,,,,,,,2492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIXATION SYNDESMOSIS ANKLE,10557201,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2925.00,877.50,1134.90,2486.25,,,,,,,,,,,,,,,,,,,,1134.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2193.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1462.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2486.25,,,percent of total billed charges,,,1316.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIXATION SYNDESMOSIS ANKLE,10557201,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2925.00,877.50,1243.12,2486.25,,,,,,,,,,,,,service not payable,,,,,,,1475.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1243.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2193.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1462.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2193.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2486.25,,,percent of total billed charges,,,1345.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB DIST 8H LT 132MM,10557202,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3126.00,937.80,1212.89,2657.10,,,,,,,,,,,,,,,,,,,,1212.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1328.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2344.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1563.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2657.10,,,percent of total billed charges,,,1406.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB DIST 8H LT 132MM,10557202,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3126.00,937.80,1328.55,2657.10,,,,,,,,,,,,,service not payable,,,,,,,1576.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1328.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2344.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1563.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2344.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2657.10,,,percent of total billed charges,,,1437.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLX DELTA OPTION 40MM 0,10557203,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLX DELTA OPTION 40MM 0,10557203,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM M/L SZ9,10557204,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM M/L SZ9,10557204,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MESA 6.5X45MM,10557205,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MESA 6.5X45MM,10557205,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR SPINE POST 0DEG SM X_03820134 X_STRYKER,10557206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2485.00,745.50,964.18,2112.25,,,,,,,,,,,,,,,,,,,,964.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1863.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1242.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2112.25,,,percent of total billed charges,,,1118.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SPINE POST 0DEG SM X_03820134 X_STRYKER,10557206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2485.00,745.50,1056.12,2112.25,,,,,,,,,,,,,service not payable,,,,,,,1253.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1863.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1242.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1863.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2112.25,,,percent of total billed charges,,,1143.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF 5X160X55MM,10557207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF 5X160X55MM,10557207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF 4X100X35MM,10557208,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF 4X100X35MM,10557208,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BAR 11X150MM,10557209,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BAR 11X150MM,10557209,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BAR 11X200MM,10557210,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BAR 11X200MM,10557210,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE ANT TLIF 8X14X34 120DEG,10557212,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE ANT TLIF 8X14X34 120DEG,10557212,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM POS SZ4 8MM,10557213,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM POS SZ4 8MM,10557213,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM DIST SZ4 8MM,10557214,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM DIST SZ4 8MM,10557214,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT PLATFORM ROT SZ4 12MM,10557215,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT PLATFORM ROT SZ4 12MM,10557215,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR KK 40X56MM,10557216,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR KK 40X56MM,10557216,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Removal of Temporary VAD,10557330,CDM,0481,RC,33992,CPT,,,,,,outpatient,facility,,,10928.00,3278.40,195.63,9288.80,,7119.04,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,5512.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.0,,,case rate,,,,,,,,,8196.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.0,,,case rate,,,,,,,,service not payable,8196.0,,,percent of total billed charges,,,195.63,,,fee schedule,,,,,,,,service not payable,,,,,,,9288.80,,,percent of total billed charges,,,5026.88,,,percent of total billed charges,,,,,,,,,7856.0,,,case rate,,,,,,,,service not payable,,,,,,,6913.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Removal of Temporary VAD,10557330,CDM,0481,RC,33992,CPT,87,EAPG,,,,outpatient,facility,,,10928.00,3278.40,10511.79,20552.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20552.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,17469.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,10511.79,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12703.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,13973.5,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Revascularization endovasc Iliac artery w/angiopla,10557333,CDM,0481,RC,37220,CPT,,,,,,outpatient,facility,,,14875.00,4462.50,5463.36,12795.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,7502.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,11156.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,11156.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12643.75,,,percent of total billed charges,,,6842.5,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Revascularization endovasc Iliac artery w/angiopla,10557333,CDM,0481,RC,37220,CPT,05192,APC,,,,outpatient,facility,,,14875.00,4462.50,5244.41,12557.62,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,11501.89,,,fee schedule,,,5244.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5576.92,,,fee schedule,,,12557.62,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,11335.20,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,5244.41,,,fee schedule,,,5576.92,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,5244.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5576.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,5522.02,,,fee schedule,,,,,,,,
Revascularization endovasc Iliac artery w/angiopla,10557333,CDM,0481,RC,37220,CPT,79,EAPG,,,,outpatient,facility,,,14875.00,4462.50,6925.40,15648.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15648.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13301.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6925.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,7617.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Dexamethasone Level (2003248),10557523,CDM,0300,RC,80299,CPT,,,,,,outpatient,facility,,,131.00,39.30,17.71,111.35,,58.21,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,18.27,,,fee schedule,,,43.43,,,fee schedule,,,38.88,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,38.58,,,fee schedule,,,17.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",18.64,,,fee schedule,,,42.13,,,fee schedule,,,,,,,,,18.27,,,fee schedule,,,,,,,,,24.02,,,fee schedule,,,38.03,,,fee schedule,,,98.25,,,percent of total billed charges,,,18.27,,,fee schedule,,,17.71,,,fee schedule,,,18.64,,,fee schedule,,,28.25,,,fee schedule,,,18.27,,,fee schedule,,,98.25,,,percent of total billed charges,,,,,,,,,18.64,,,fee schedule,,,,,,,,,111.35,,,percent of total billed charges,,,60.26,,,percent of total billed charges,,,,,,,,,20.5,,,fee schedule,,,18.27,,,fee schedule,,,,,,,,,18.08,,,fee schedule,,,18.27,,,fee schedule,,,,,,,,,18.45,,,fee schedule,,,,,,,,
Dexamethasone Level (2003248),10557523,CDM,0300,RC,80299,CPT,405,EAPG,,,,outpatient,facility,,,131.00,39.30,14.30,137.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,116.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,66.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE VA-LCP LARGE 2.4/2.7MM,10557529,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4659.00,1397.70,1807.69,3960.15,,,,,,,,,,,,,,,,,,,,1807.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3494.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2329.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3960.15,,,percent of total billed charges,,,2096.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP LARGE 2.4/2.7MM,10557529,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4659.00,1397.70,1980.08,3960.15,,,,,,,,,,,,,service not payable,,,,,,,2350.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1980.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3494.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2329.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3494.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3960.15,,,percent of total billed charges,,,2143.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP 2H 2.4/2.7MM,10557530,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4236.00,1270.80,1643.57,3600.60,,,,,,,,,,,,,,,,,,,,1643.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1800.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2118.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.60,,,percent of total billed charges,,,1906.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP 2H 2.4/2.7MM,10557530,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4236.00,1270.80,1800.3,3600.60,,,,,,,,,,,,,service not payable,,,,,,,2136.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1800.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3177.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2118.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3177.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3600.60,,,percent of total billed charges,,,1948.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON PRESS REGUL 51-60CM,10557532,CDM,0278,RC,C1815,HCPCS,,,,,,inpatient,facility,,,11802.00,3540.60,4579.18,10031.70,,5782.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4956.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4579.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8851.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5901.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10031.70,,,percent of total billed charges,,,5310.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON PRESS REGUL 51-60CM,10557532,CDM,0278,RC,C1815,HCPCS,,,,,,outpatient,facility,,,11802.00,3540.60,4956.84,10031.70,,5782.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4956.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5952.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8851.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5901.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8851.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10031.70,,,percent of total billed charges,,,5428.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON PRESS REGUL 71-80CM,10557533,CDM,0278,RC,C1815,HCPCS,,,,,,inpatient,facility,,,11802.00,3540.60,4579.18,10031.70,,5782.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4956.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4579.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8851.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5901.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10031.70,,,percent of total billed charges,,,5310.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON PRESS REGUL 71-80CM,10557533,CDM,0278,RC,C1815,HCPCS,,,,,,outpatient,facility,,,11802.00,3540.60,4956.84,10031.70,,5782.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4956.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5952.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8851.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5901.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8851.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10031.70,,,percent of total billed charges,,,5428.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUFF OCCLUS W/IZ 6CM,10557534,CDM,0278,RC,C1815,HCPCS,,,,,,inpatient,facility,,,22899.00,6869.70,8884.81,19464.15,,11220.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9617.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8884.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9732.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17174.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11449.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19464.15,,,percent of total billed charges,,,10304.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUFF OCCLUS W/IZ 6CM,10557534,CDM,0278,RC,C1815,HCPCS,,,,,,outpatient,facility,,,22899.00,6869.70,9617.58,19464.15,,11220.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9617.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11550.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9732.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17174.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11449.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17174.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19464.15,,,percent of total billed charges,,,10533.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFN CANN RT 130D 380X14MM,10557536,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFN CANN RT 130D 380X14MM,10557536,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT BONE TRAUMACEM,10557537,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,2707.00,812.10,1050.32,2300.95,,,,,,,,,,,,,,,,,,,,1050.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2030.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1353.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2300.95,,,percent of total billed charges,,,1218.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT BONE TRAUMACEM,10557537,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,2707.00,812.10,1150.47,2300.95,,,,,,,,,,,,,service not payable,,,,,,,1365.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2030.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1353.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2030.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2300.95,,,percent of total billed charges,,,1245.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT BONE TRAUMACEM,10557537,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,2707.00,812.10,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT CANNULA TRAUMACEM TNFA,10557540,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,2444.00,733.20,948.27,2077.40,,,,,,,,,,,,,,,,,,,,948.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1038.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1833.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1222.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2077.40,,,percent of total billed charges,,,1099.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT CANNULA TRAUMACEM TNFA,10557540,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,2444.00,733.20,1038.7,2077.40,,,,,,,,,,,,,service not payable,,,,,,,1232.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1038.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1833.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1222.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1833.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2077.40,,,percent of total billed charges,,,1124.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENT CANNULA TRAUMACEM TNFA,10557540,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,2444.00,733.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 21.0,10557542,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 21.0,10557542,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH PTA DCB 5X60MM 130CM,10557547,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4360.00,1308.00,1853.0,3706.0,,2694.48,,,percent of total billed charges,,,,,,,,service not payable,2127.68,,,percent of total billed charges,,,2199.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1853.0,,,percent of total billed charges,,,,,,,,,3270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2180.0,,,percent of total billed charges,,,,,,,,service not payable,3270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3706.0,,,percent of total billed charges,,,2005.60,,,percent of total billed charges,,,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2834.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD OASYS 3.5X70MM,10557548,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,536.00,160.80,207.97,455.60,,,,,,,,,,,,,,,,,,,,207.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.60,,,percent of total billed charges,,,241.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD OASYS 3.5X70MM,10557548,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,536.00,160.80,227.80,455.60,,,,,,,,,,,,,service not payable,,,,,,,270.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,402.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,455.60,,,percent of total billed charges,,,246.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM POST STAB SZ 6 LFT,10557549,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM POST STAB SZ 6 LFT,10557549,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM CMNTD HIGH OFST SZ 6,10557550,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM CMNTD HIGH OFST SZ 6,10557550,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER DISTAL EMNT UNIV 19MM,10557551,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER DISTAL EMNT UNIV 19MM,10557551,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM P S NAR SZ 6N RT,10557552,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM P S NAR SZ 6N RT,10557552,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER PFRK PE BI MENTUM 28/47,10557553,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER PFRK PE BI MENTUM 28/47,10557553,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP PFRK PFIT BI MEMTUM 47,10557554,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP PFRK PFIT BI MEMTUM 47,10557554,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CRV 5.5  65MM X_1119.7065 X_GLOBUS,10557555,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CRV 5.5  65MM X_1119.7065 X_GLOBUS,10557555,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CRV 5.5 70MM X_1119.7070 X_GLOBUS,10557556,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CRV 5.5 70MM X_1119.7070 X_GLOBUS,10557556,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Transesophageal echo cardiogram (TEE),10558643,CDM,0481,RC,93312,CPT,,,,,,outpatient,facility,,,1900.00,570.00,392.42,1615.0,,525.91,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,392.42,,,fee schedule,,,958.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,807.5,,,percent of total billed charges,,,,,,,,,1425.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,950.0,,,percent of total billed charges,,,,,,,,,1425.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1615.0,,,percent of total billed charges,,,874.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Transesophageal echo cardiogram (TEE),10558643,CDM,0481,RC,93312,CPT,05524,APC,,,,outpatient,facility,,,1900.00,570.00,504.34,1207.63,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,1106.10,,,fee schedule,,,504.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",536.32,,,fee schedule,,,1207.63,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,1090.07,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,504.34,,,fee schedule,,,536.32,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,,,,,,,504.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",536.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,525.80,,,fee schedule,,,,,,,,,531.03,,,fee schedule,,,,,,,,
Transesophageal echo cardiogram (TEE),10558643,CDM,0481,RC,93312,CPT,81,EAPG,,,,outpatient,facility,,,1900.00,570.00,630.02,1789.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1789.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1520.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1051.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1156.67,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW 5.5 CREO 6.5X50MM X_5119.1650 X_GLOBAL SURGI,10558677,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3388.00,1016.40,1314.54,2879.80,,,,,,,,,,,,,,,,,,,,1314.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.80,,,percent of total billed charges,,,1524.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 5.5 CREO 6.5X50MM X_5119.1650 X_GLOBAL SURGI,10558677,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3388.00,1016.40,1439.90,2879.80,,,,,,,,,,,,,service not payable,,,,,,,1708.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1439.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2541.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2541.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2879.80,,,percent of total billed charges,,,1558.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE XTEND 38MM 0MM,10558678,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE XTEND 38MM 0MM,10558678,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 1.6 X 14MM,10558679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.6 X 14MM,10558679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 1.6 X 13MM,10558680,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.6 X 13MM,10558680,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 1.6 X 11MM,10558681,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.6 X 11MM,10558681,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM VESUVIUS 15CC,10558684,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,6262.00,1878.60,2429.66,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2429.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5322.70,,,percent of total billed charges,,,2817.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE DBM VESUVIUS 15CC,10558684,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,6262.00,1878.60,2630.04,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3158.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5322.70,,,percent of total billed charges,,,2880.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM VESUVIUS 15CC,10558684,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,6262.00,1878.60,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT BIO CANC 15CCX1-8MM,10558685,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,1294.00,388.20,502.07,1099.90,,,,,,,,,,,,,,,,,,,,502.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,970.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,647.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1099.90,,,percent of total billed charges,,,582.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT BIO CANC 15CCX1-8MM,10558685,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,1294.00,388.20,549.95,1099.90,,,,,,,,,,,,,service not payable,,,,,,,652.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,549.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,970.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,647.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,970.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1099.90,,,percent of total billed charges,,,595.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT BIO CANC 15CCX1-8MM,10558685,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,1294.00,388.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL HIN XXSM 12MM,10558686,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12439.00,3731.70,4826.33,10573.15,,6095.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5224.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4826.33,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5286.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9329.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6219.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10573.15,,,percent of total billed charges,,,5597.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL HIN XXSM 12MM,10558686,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12439.00,3731.70,5224.38,10573.15,,6095.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5224.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6274.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5286.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9329.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6219.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9329.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10573.15,,,percent of total billed charges,,,5721.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS UV TORIC ASPHERIC 19.5D,10558688,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS UV TORIC ASPHERIC 19.5D,10558688,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING KNEE TIBIAL 71-75X16MM,10558689,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE TIBIAL 71-75X16MM,10558689,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE T5 1.7X15MM,10560460,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,797.00,239.10,309.24,677.45,,,,,,,,,,,,,,,,,,,,309.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,597.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,677.45,,,percent of total billed charges,,,358.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE T5 1.7X15MM,10560460,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,797.00,239.10,338.72,677.45,,,,,,,,,,,,,service not payable,,,,,,,402.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,338.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,597.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,398.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,597.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,677.45,,,percent of total billed charges,,,366.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T5 1.7X12MM,10560461,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1015.00,304.50,393.82,862.75,,,,,,,,,,,,,,,,,,,,393.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T5 1.7X12MM,10560461,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1015.00,304.50,431.38,862.75,,,,,,,,,,,,,service not payable,,,,,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,761.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T5 1.7X16MM,10560462,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1015.00,304.50,393.82,862.75,,,,,,,,,,,,,,,,,,,,393.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T5 1.7X16MM,10560462,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1015.00,304.50,431.38,862.75,,,,,,,,,,,,,service not payable,,,,,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,761.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 10 H DISTAL LT,10560463,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4671.00,1401.30,1812.35,3970.35,,,,,,,,,,,,,,,,,,,,1812.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1985.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3503.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2335.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3970.35,,,percent of total billed charges,,,2101.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 10 H DISTAL LT,10560463,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4671.00,1401.30,1985.18,3970.35,,,,,,,,,,,,,service not payable,,,,,,,2356.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1985.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3503.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2335.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3503.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3970.35,,,percent of total billed charges,,,2148.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANCELLOUS 6.0X45MM,10560464,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,930.00,279.00,360.84,790.5,,,,,,,,,,,,,,,,,,,,360.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANCELLOUS 6.0X45MM,10560464,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,,,,,,,,,,,,service not payable,,,,,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NATURAL 13MM X 38CM,10560465,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5754.00,1726.20,2232.55,4890.90,,2819.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2416.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2232.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2445.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4315.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2877.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4890.90,,,percent of total billed charges,,,2589.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NATURAL 13MM X 38CM,10560465,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5754.00,1726.20,2416.68,4890.90,,2819.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2416.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2902.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2445.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4315.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2877.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4315.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4890.90,,,percent of total billed charges,,,2646.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEPIN 3.0X355MM,10560466,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDEPIN 3.0X355MM,10560466,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUMERAL 8H RT 3.5MM,10560467,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8085.00,2425.50,3136.98,6872.25,,3961.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3395.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3136.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3436.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6063.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4042.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6872.25,,,percent of total billed charges,,,3638.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUMERAL 8H RT 3.5MM,10560467,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8085.00,2425.50,3395.70,6872.25,,3961.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3395.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4078.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3436.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6063.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4042.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6063.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6872.25,,,percent of total billed charges,,,3719.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE SAFARI2 LG CRV 275CM,10560469,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE SAF-2 XS CRV 275CM,10560470,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
"GWIRE SAF-2 SM CRV .035 275CM""""",10560471,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS PROTECTION SENTINEL CEREBR,10560472,CDM,0272,RC,C1884,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5573.02,11146.05,,8103.83,,,percent of total billed charges,,,,,,,,service not payable,6399.14,,,percent of total billed charges,,,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,8523.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8523.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROSTIM RECHARGEABLE SYS,10560475,CDM,0278,RC,C1820,HCPCS,,,,,,inpatient,facility,,,24762.00,7428.60,9607.66,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9607.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21047.70,,,percent of total billed charges,,,11142.9,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROSTIM RECHARGEABLE SYS,10560475,CDM,0278,RC,C1820,HCPCS,,,,,,outpatient,facility,,,24762.00,7428.60,10400.04,21047.70,,12133.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10400.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12489.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10523.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18571.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12381.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18571.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21047.70,,,percent of total billed charges,,,11390.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X58MM,10560476,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X58MM,10560476,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X90MM,10560477,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X90MM,10560477,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK 3.5X14MM,10560478,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK 3.5X14MM,10560478,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE SAF-2 LG CRV 5X4.9 275CM,10560479,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,844.81,,,percent of total billed charges,,,,,,,,service not payable,667.10,,,percent of total billed charges,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,888.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING 1.7X8MM,10561164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,797.00,239.10,309.24,677.45,,,,,,,,,,,,,,,,,,,,309.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,597.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,677.45,,,percent of total billed charges,,,358.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING 1.7X8MM,10561164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,797.00,239.10,338.72,677.45,,,,,,,,,,,,,service not payable,,,,,,,402.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,338.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,597.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,398.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,597.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,677.45,,,percent of total billed charges,,,366.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 1.7X11MM,10561165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,797.00,239.10,309.24,677.45,,,,,,,,,,,,,,,,,,,,309.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,597.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,677.45,,,percent of total billed charges,,,358.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 1.7X11MM,10561165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,797.00,239.10,338.72,677.45,,,,,,,,,,,,,service not payable,,,,,,,402.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,338.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,597.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,398.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,597.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,677.45,,,percent of total billed charges,,,366.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 9MM,10561166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 9MM,10561166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 15MM,10561167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 15MM,10561167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP CVD VA 14H 301MM RT,10561168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9135.00,2740.50,3544.38,7764.75,,4476.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3836.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3544.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3882.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6851.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4567.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7764.75,,,percent of total billed charges,,,4110.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP CVD VA 14H 301MM RT,10561168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9135.00,2740.50,3836.70,7764.75,,4476.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3836.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4607.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3882.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6851.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4567.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6851.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7764.75,,,percent of total billed charges,,,4202.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK VAR ANG 5.0X10MM,10561169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2014.00,604.20,781.43,1711.90,,,,,,,,,,,,,,,,,,,,781.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,855.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1510.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1007.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1711.90,,,percent of total billed charges,,,906.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK VAR ANG 5.0X10MM,10561169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2014.00,604.20,855.95,1711.90,,,,,,,,,,,,,service not payable,,,,,,,1015.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,855.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1510.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1007.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1510.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1711.90,,,percent of total billed charges,,,926.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK VAR ANG 5.0X14MM,10561170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2014.00,604.20,781.43,1711.90,,,,,,,,,,,,,,,,,,,,781.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,855.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1510.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1007.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1711.90,,,percent of total billed charges,,,906.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK VAR ANG 5.0X14MM,10561170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2014.00,604.20,855.95,1711.90,,,,,,,,,,,,,service not payable,,,,,,,1015.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,855.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1510.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1007.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1510.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1711.90,,,percent of total billed charges,,,926.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN POSITIONING 5.0MM STERILE,10561171,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1664.00,499.20,645.63,1414.40,,,,,,,,,,,,,,,,,,,,645.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,707.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1248.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,832.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1414.40,,,percent of total billed charges,,,748.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN POSITIONING 5.0MM STERILE,10561171,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1664.00,499.20,707.20,1414.40,,,,,,,,,,,,,service not payable,,,,,,,839.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,707.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1248.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,832.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1248.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1414.40,,,percent of total billed charges,,,765.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM M/L TAPER SZ11 X121MM,10561172,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM M/L TAPER SZ11 X121MM,10561172,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM UNIPOL 44MM_Zimmer Biomet_00-7818-044-00,10561173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM UNIPOL 44MM_Zimmer Biomet_00-7818-044-00,10561173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LIGAMENT RECONST DELT KIT,10561174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6409.00,1922.70,2486.69,5447.65,,3140.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2691.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2486.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2723.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4806.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5447.65,,,percent of total billed charges,,,2884.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIGAMENT RECONST DELT KIT,10561174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6409.00,1922.70,2691.78,5447.65,,3140.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2691.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3232.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2723.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4806.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3204.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4806.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5447.65,,,percent of total billed charges,,,2948.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART KNEE RT 6-9 CD 11MM,10564772,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART KNEE RT 6-9 CD 11MM,10564772,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NCB ST 5.0X16MM,10564773,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,793.00,237.90,307.68,674.05,,,,,,,,,,,,,,,,,,,,307.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.05,,,percent of total billed charges,,,356.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NCB ST 5.0X16MM,10564773,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,793.00,237.90,337.02,674.05,,,,,,,,,,,,,service not payable,,,,,,,399.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,337.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,594.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,396.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,594.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,674.05,,,percent of total billed charges,,,364.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS PEEK 4D 11X20X11MM,10564774,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,6105.00,1831.50,2368.74,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5189.25,,,percent of total billed charges,,,2747.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS PEEK 4D 11X20X11MM,10564774,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,6105.00,1831.50,2564.10,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3079.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5189.25,,,percent of total billed charges,,,2808.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THOR 40X34MM 94MM,10564775,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,40421.00,12126.30,15683.35,34357.85,,19806.29,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16976.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15683.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17178.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,30315.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20210.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34357.85,,,percent of total billed charges,,,18189.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THOR 40X34MM 94MM,10564775,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,40421.00,12126.30,16976.82,34357.85,,19806.29,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16976.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,20388.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17178.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,30315.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20210.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,30315.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34357.85,,,percent of total billed charges,,,18593.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DISTAL CENTRALIZER SZ 13,10564777,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DISTAL CENTRALIZER SZ 13,10564777,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR HW G7 36MM D,10564778,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR HW G7 36MM D,10564778,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPEEDBRIDGE LE 4.75X19.1,10564779,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6262.00,1878.60,2429.66,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2429.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5322.70,,,percent of total billed charges,,,2817.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPEEDBRIDGE LE 4.75X19.1,10564779,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6262.00,1878.60,2630.04,5322.70,,3068.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2630.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3158.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2661.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4696.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4696.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5322.70,,,percent of total billed charges,,,2880.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFN CANN LT 130D 420X14MM,10564780,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFN CANN LT 130D 420X14MM,10564780,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT ACL TIGHTROPE FIBERTAG,10564783,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1831.00,549.30,710.43,1556.35,,,,,,,,,,,,,,,,,,,,710.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1373.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,915.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.35,,,percent of total billed charges,,,823.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT ACL TIGHTROPE FIBERTAG,10564783,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1831.00,549.30,778.17,1556.35,,,,,,,,,,,,,service not payable,,,,,,,923.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,778.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1373.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,915.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1373.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1556.35,,,percent of total billed charges,,,842.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Evaluation Swallow with Materials - Speech Therap,10565020,CDM,0440,RC,92611,CPT,,,,,GN  ,outpatient,facility,,,562.00,168.60,82.83,477.70,,347.32,,,percent of total billed charges,,,82.90,,,fee schedule,,,274.26,,,percent of total billed charges,,,283.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,174.40,,,fee schedule,,,98.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.49,,,fee schedule,,,190.25,,,fee schedule,,,,,,,,,82.83,,,fee schedule,,,,,,,,,173.0,,,per diem,,,171.87,,,fee schedule,,,421.5,,,percent of total billed charges,,,82.90,,,fee schedule,,,98.71,,,fee schedule,,,84.56,,,fee schedule,,,204.0,,,per diem,,,82.83,,,fee schedule,,,421.5,,,percent of total billed charges,,,98.71,,,fee schedule,,,84.56,,,fee schedule,,,,,,,,,477.70,,,percent of total billed charges,,,258.52,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,82.83,,,fee schedule,,,,,,,,,229.0,,,per diem,,,82.90,,,fee schedule,,,,,,,,,82.90,,,fee schedule,,,,,,,,
Evaluation Swallow with Materials - Speech Therap,10565020,CDM,0440,RC,92611,CPT,389,EAPG,,,GN  ,outpatient,facility,,,562.00,168.60,172.18,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,172.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,261.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,287.80,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT FIBERTAG TIGHTROPE ACL,10565060,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT FIBERTAG TIGHTROPE ACL,10565060,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 20.5D,10565063,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 20.5D,10565063,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD MOD T1  12MM OFFSET 32MM,10565064,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD MOD T1  12MM OFFSET 32MM,10565064,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE G7 LPR DOME 6.5X35,10565065,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE G7 LPR DOME 6.5X35,10565065,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM HIP ECHO FX 9.0MM,10565066,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM HIP ECHO FX 9.0MM,10565066,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL LPS 13X125MM,10565067,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15835.00,4750.50,6143.98,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6143.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13459.75,,,percent of total billed charges,,,7125.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL LPS 13X125MM,10565067,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15835.00,4750.50,6650.70,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7987.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13459.75,,,percent of total billed charges,,,7284.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
JUGGERKNOT SHORT 1.4MM SZ 1,10565068,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2172.00,651.60,842.74,1846.2,,,,,,,,,,,,,,,,,,,,842.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,923.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1629.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1086.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1846.2,,,percent of total billed charges,,,977.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JUGGERKNOT SHORT 1.4MM SZ 1,10565068,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2172.00,651.60,923.10,1846.2,,,,,,,,,,,,,service not payable,,,,,,,1095.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,923.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1629.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1086.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1629.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1846.2,,,percent of total billed charges,,,999.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH LIGTNING 12 100 CM,10565070,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,22325.00,6697.50,9488.13,18976.25,,13796.85,,,percent of total billed charges,,,,,,,,service not payable,10894.6,,,percent of total billed charges,,,11260.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9488.13,,,percent of total billed charges,,,,,,,,,16743.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11162.5,,,percent of total billed charges,,,,,,,,service not payable,16743.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18976.25,,,percent of total billed charges,,,10269.5,,,percent of total billed charges,,,,,,,,,14511.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,14511.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER 6F NEURON 053,10565071,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2995.00,898.50,1272.88,2545.75,,1850.91,,,percent of total billed charges,,,,,,,,service not payable,1461.56,,,percent of total billed charges,,,1510.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1272.88,,,percent of total billed charges,,,,,,,,,2246.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1497.5,,,percent of total billed charges,,,,,,,,service not payable,2246.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2545.75,,,percent of total billed charges,,,1377.7,,,percent of total billed charges,,,,,,,,,1946.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1946.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER 6F NEURON 070,10565072,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2995.00,898.50,1272.88,2545.75,,1850.91,,,percent of total billed charges,,,,,,,,service not payable,1461.56,,,percent of total billed charges,,,1510.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1272.88,,,percent of total billed charges,,,,,,,,,2246.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1497.5,,,percent of total billed charges,,,,,,,,service not payable,2246.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2545.75,,,percent of total billed charges,,,1377.7,,,percent of total billed charges,,,,,,,,,1946.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1946.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X28MM,10565073,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X28MM,10565073,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PLANTAR LAPIDUS SHORT RT,10565074,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PLANTAR LAPIDUS SHORT RT,10565074,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 140CC,10565754,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5983.00,1794.90,2321.40,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2321.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.55,,,percent of total billed charges,,,2692.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 140CC,10565754,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5983.00,1794.90,2512.86,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3017.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5085.55,,,percent of total billed charges,,,2752.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSL 170CC,10565755,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5983.00,1794.90,2321.40,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2321.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.55,,,percent of total billed charges,,,2692.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSL 170CC,10565755,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5983.00,1794.90,2512.86,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3017.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5085.55,,,percent of total billed charges,,,2752.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST SMOOTH SOFT 165CC,10565756,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5983.00,1794.90,2321.40,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2321.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.55,,,percent of total billed charges,,,2692.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST SMOOTH SOFT 165CC,10565756,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5983.00,1794.90,2512.86,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3017.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5085.55,,,percent of total billed charges,,,2752.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 140CC,10565757,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5983.00,1794.90,2321.40,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2321.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.55,,,percent of total billed charges,,,2692.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 140CC,10565757,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5983.00,1794.90,2512.86,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3017.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5085.55,,,percent of total billed charges,,,2752.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 175CC,10565758,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5983.00,1794.90,2321.40,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2321.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.55,,,percent of total billed charges,,,2692.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 175CC,10565758,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5983.00,1794.90,2512.86,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3017.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5085.55,,,percent of total billed charges,,,2752.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIRA SSM 195CC,10565759,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5983.00,1794.90,2321.40,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2321.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.55,,,percent of total billed charges,,,2692.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIRA SSM 195CC,10565759,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5983.00,1794.90,2512.86,5085.55,,2931.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2512.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3017.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2542.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4487.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2991.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4487.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5085.55,,,percent of total billed charges,,,2752.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 32MM SZHH,10565760,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 32MM SZHH,10565760,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM SZ6 TAPER,10565761,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM SZ6 TAPER,10565761,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL 15X140MM,10565762,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL 15X140MM,10565762,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER PROXIMAL 15MM,10565763,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER PROXIMAL 15MM,10565763,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER DISTAL 13MM,10565764,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER DISTAL 13MM,10565764,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIB 1/3 3.5MM 10H 133MM,10565766,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,974.00,292.20,377.91,827.90,,,,,,,,,,,,,,,,,,,,377.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,730.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,487.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,827.90,,,percent of total billed charges,,,438.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB 1/3 3.5MM 10H 133MM,10565766,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,974.00,292.20,413.95,827.90,,,,,,,,,,,,,service not payable,,,,,,,491.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,730.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,487.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,730.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,827.90,,,percent of total billed charges,,,448.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANNULATED 4 X 44MM,10565767,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANNULATED 4 X 44MM,10565767,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW REV CENT 9.5X35MM,10565768,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW REV CENT 9.5X35MM,10565768,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 13MMX36CM 130 DEG,10565769,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 13MMX36CM 130 DEG,10565769,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT ARTICULAR LT SZ5-6,10565770,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT ARTICULAR LT SZ5-6,10565770,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD SPINE XIA 3 RADIAL 6X30MM,10565771,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,536.00,160.80,207.97,455.60,,,,,,,,,,,,,,,,,,,,207.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.60,,,percent of total billed charges,,,241.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD SPINE XIA 3 RADIAL 6X30MM,10565771,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,536.00,160.80,227.80,455.60,,,,,,,,,,,,,service not payable,,,,,,,270.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,402.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,402.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,455.60,,,percent of total billed charges,,,246.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR HH 50MM,10566668,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR HH 50MM,10566668,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP 12/14 TAPER 32MM,10566669,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP 12/14 TAPER 32MM,10566669,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR JJ 54MM,10566670,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR JJ 54MM,10566670,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL 12/14 TPR 36MM X_00-8018-036-04 X_ZIM,10566671,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL 12/14 TPR 36MM X_00-8018-036-04 X_ZIM,10566671,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE LCP 7H 98X3.5MM,10567007,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2553.00,765.90,990.56,2170.05,,,,,,,,,,,,,,,,,,,,990.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1085.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1914.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1276.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2170.05,,,percent of total billed charges,,,1148.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE LCP 7H 98X3.5MM,10567007,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2553.00,765.90,1085.02,2170.05,,,,,,,,,,,,,service not payable,,,,,,,1287.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1085.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1914.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1276.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1914.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2170.05,,,percent of total billed charges,,,1174.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM DIST SZ 11X10MM,10567008,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM DIST SZ 11X10MM,10567008,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV 3MM 15X135MM,10567009,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV 3MM 15X135MM,10567009,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ART SURF REV CCK 11-13 GH 18MM,10567010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ART SURF REV CCK 11-13 GH 18MM,10567010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR REV SZ11 LFT,10567011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23357.00,7007.10,9062.52,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9062.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19853.45,,,percent of total billed charges,,,10510.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR REV SZ11 LFT,10567011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23357.00,7007.10,9809.94,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11781.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19853.45,,,percent of total billed charges,,,10744.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB SPLINED REV 18X135MM,10567012,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5655.00,1696.50,2194.14,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2194.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4806.75,,,percent of total billed charges,,,2544.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB SPLINED REV 18X135MM,10567012,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5655.00,1696.50,2375.10,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2852.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4806.75,,,percent of total billed charges,,,2601.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT TIB REV FIX KEEL SZ G,10567013,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT TIB REV FIX KEEL SZ G,10567013,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TFNA FENESTRATED 85MM,10567014,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TFNA FENESTRATED 85MM,10567014,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS-FLEX GSF LFT SZ E,10567015,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS-FLEX GSF LFT SZ E,10567015,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS 2ND FIX W BC SWVLC,10567016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS 2ND FIX W BC SWVLC,10567016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CEMENT BONE STERILE DISP,10567017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1748.00,524.40,678.22,1485.8,,,,,,,,,,,,,,,,,,,,678.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.8,,,percent of total billed charges,,,786.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT CEMENT BONE STERILE DISP,10567017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1748.00,524.40,742.90,1485.8,,,,,,,,,,,,,service not payable,,,,,,,881.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,742.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1311.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,874.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1311.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1485.8,,,percent of total billed charges,,,804.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT QUAD LINK FROZEN,10567018,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,8097.00,2429.10,3141.64,6882.45,,3967.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3400.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3141.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3441.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6072.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6882.45,,,percent of total billed charges,,,3643.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT QUAD LINK FROZEN,10567018,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,8097.00,2429.10,3400.74,6882.45,,3967.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3400.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4084.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3441.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6072.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6072.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6882.45,,,percent of total billed charges,,,3724.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMP ENDURANT 3PC CASE,10567020,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,30160.00,9048.00,11702.08,25636.0,,14778.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12667.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11702.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12818.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22620.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15080.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25636.0,,,percent of total billed charges,,,13572.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMP ENDURANT 3PC CASE,10567020,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,30160.00,9048.00,12667.20,25636.0,,14778.4,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12667.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15212.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12818.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22620.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15080.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22620.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,25636.0,,,percent of total billed charges,,,13873.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.3X10MM,10567024,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.3X10MM,10567024,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 2.3X12MM,10567025,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 2.3X12MM,10567025,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM POST STAB SZ 5 LFT,10567026,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM POST STAB SZ 5 LFT,10567026,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT CONTRA LIMB 16X28X156MM,10567551,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,18882.00,5664.60,7326.22,16049.70,,9252.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7930.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7326.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8024.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9441.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16049.70,,,percent of total billed charges,,,8496.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT CONTRA LIMB 16X28X156MM,10567551,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,18882.00,5664.60,7930.44,16049.70,,9252.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7930.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9524.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8024.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14161.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9441.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14161.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16049.70,,,percent of total billed charges,,,8685.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB RT MEDIAL SZ 6,10567552,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5083.00,1524.90,1972.20,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1972.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4320.55,,,percent of total billed charges,,,2287.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB RT MEDIAL SZ 6,10567552,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5083.00,1524.90,2134.86,4320.55,,2490.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2134.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2563.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2160.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4320.55,,,percent of total billed charges,,,2338.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB RT MEDIAL SZ G,10567553,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB RT MEDIAL SZ G,10567553,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING KNEE TIB PERS SZ G 9MM,10567554,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING KNEE TIB PERS SZ G 9MM,10567554,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT MIDFACE,10567556,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,25570.00,7671.00,9921.16,21734.5,,12529.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10739.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9921.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10867.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19177.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12785.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21734.5,,,percent of total billed charges,,,11506.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT MIDFACE,10567556,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,25570.00,7671.00,10739.4,21734.5,,12529.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10739.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12897.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10867.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19177.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12785.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19177.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21734.5,,,percent of total billed charges,,,11762.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RESORBX MINI 8H,10567557,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1274.00,382.20,494.31,1082.90,,,,,,,,,,,,,,,,,,,,494.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,955.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,637.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1082.90,,,percent of total billed charges,,,573.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RESORBX MINI 8H,10567557,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1274.00,382.20,541.45,1082.90,,,,,,,,,,,,,service not payable,,,,,,,642.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,541.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,955.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,637.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,955.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1082.90,,,percent of total billed charges,,,586.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN SH 125D 420X12MM,10567559,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN SH 125D 420X12MM,10567559,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PERI 2.7MM HEAD 3.5X52MM,10567560,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERI 2.7MM HEAD 3.5X52MM,10567560,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SNSR OPT POST CHBR 8.0D,10567561,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,956.00,286.80,370.93,812.60,,,,,,,,,,,,,,,,,,,,370.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.60,,,percent of total billed charges,,,430.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SNSR OPT POST CHBR 8.0D,10567561,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,956.00,286.80,406.30,812.60,,,,,,,,,,,,,service not payable,,,,,,,482.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,717.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,812.60,,,percent of total billed charges,,,439.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR NAT BRIDGE LP ADJ MD,10567662,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1902.00,570.60,737.98,1616.7,,,,,,,,,,,,,,,,,,,,737.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1426.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,951.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1616.7,,,percent of total billed charges,,,855.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR NAT BRIDGE LP ADJ MD,10567662,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1902.00,570.60,808.35,1616.7,,,,,,,,,,,,,service not payable,,,,,,,959.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,808.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1426.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,951.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1426.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1616.7,,,percent of total billed charges,,,874.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BASE 8X42X30 10DEG X_6953810 X_NUVASIVE,10567686,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BASE 8X42X30 10DEG X_6953810 X_NUVASIVE,10567686,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD QUADRIPOLAR 5F 16MMX75CM,10568506,CDM,0278,RC,C1900,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD QUADRIPOLAR 5F 16MMX75CM,10568506,CDM,0278,RC,C1900,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN FIX AVIATOR 5X14X11MM,10568507,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,891.00,267.30,345.71,757.35,,,,,,,,,,,,,,,,,,,,345.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,668.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,445.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.35,,,percent of total billed charges,,,400.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN FIX AVIATOR 5X14X11MM,10568507,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,891.00,267.30,378.68,757.35,,,,,,,,,,,,,service not payable,,,,,,,449.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,378.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,668.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,445.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,668.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,757.35,,,percent of total billed charges,,,409.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 8MM,10568508,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 8MM,10568508,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 6.0X20MM,10568509,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 6.0X20MM,10568509,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 6.0X40MM,10568510,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,330.00,99.00,128.04,280.5,,,,,,,,,,,,,,,,,,,,128.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 6.0X40MM,10568510,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,330.00,99.00,140.25,280.5,,,,,,,,,,,,,service not payable,,,,,,,166.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,247.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,165.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,247.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,280.5,,,percent of total billed charges,,,151.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEM DIST LAT RT 6H/166MM,10568511,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10639.00,3191.70,4127.93,9043.15,,5213.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4468.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4127.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4521.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7979.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5319.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9043.15,,,percent of total billed charges,,,4787.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEM DIST LAT RT 6H/166MM,10568511,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10639.00,3191.70,4468.38,9043.15,,5213.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4468.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5366.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4521.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7979.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5319.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7979.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9043.15,,,percent of total billed charges,,,4893.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT CONTRAL LIMB 16X13X82MM,10568578,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,14310.00,4293.00,5552.28,12163.5,,7011.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6010.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5552.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6081.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10732.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7155.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12163.5,,,percent of total billed charges,,,6439.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT CONTRAL LIMB 16X13X82MM,10568578,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,14310.00,4293.00,6010.20,12163.5,,7011.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6010.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7217.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6081.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10732.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7155.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10732.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12163.5,,,percent of total billed charges,,,6582.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE RT 6-9 CD 11MM,10568579,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE RT 6-9 CD 11MM,10568579,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA NEXGEN 10X38MM,10568580,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA NEXGEN 10X38MM,10568580,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT AVANCE NERVE 2-3MM 15MM,10568582,CDM,0278,RC,C9352,HCPCS,,,,,,inpatient,facility,,,7924.00,2377.20,3074.51,6735.40,,3882.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3328.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3074.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3367.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5943.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3962.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6735.40,,,percent of total billed charges,,,3565.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT AVANCE NERVE 2-3MM 15MM,10568582,CDM,0278,RC,C9352,HCPCS,,,,,,outpatient,facility,,,7924.00,2377.20,3328.08,6735.40,,3882.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3328.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3996.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3367.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5943.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3962.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5943.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6735.40,,,percent of total billed charges,,,3645.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT AVANCE NERVE 2-3MM 15MM,10568582,CDM,0278,RC,C9352,HCPCS,455,EAPG,,,,outpatient,facility,,,7924.00,2377.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Drainage Peritoneal Abscess Percutaneous w/Image,10570443,CDM,0361,RC,49406,CPT,,,,,,outpatient,facility,,,4165.00,1249.50,1915.90,4165.0,,4165.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,2100.83,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3540.25,,,percent of total billed charges,,,1915.90,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Drainage Peritoneal Abscess Percutaneous w/Image,10570443,CDM,0361,RC,49406,CPT,05072,APC,,,,outpatient,facility,,,4165.00,1249.50,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
Drainage Peritoneal Abscess Percutaneous w/Image,10570443,CDM,0361,RC,49406,CPT,150,EAPG,,,,outpatient,facility,,,4165.00,1249.50,1049.65,3313.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3313.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2816.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1049.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1049.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1158.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1273.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CONNECTOR SPINE NAT BRDG SM,10570733,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2536.00,760.80,983.97,2155.60,,,,,,,,,,,,,,,,,,,,983.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2155.60,,,percent of total billed charges,,,1141.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR SPINE NAT BRDG SM,10570733,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2536.00,760.80,1077.8,2155.60,,,,,,,,,,,,,service not payable,,,,,,,1279.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1077.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1902.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1268.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1902.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2155.60,,,percent of total billed charges,,,1166.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE 20-30 WHITE SZ 2,10570734,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,224.00,67.20,30.36,190.40,,138.43,,,percent of total billed charges,,,,,,,,service not payable,109.31,,,percent of total billed charges,,,112.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,95.20,,,percent of total billed charges,,,,,,,,,168.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,112.0,,,percent of total billed charges,,,,,,,,service not payable,168.0,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,190.40,,,percent of total billed charges,,,103.04,,,percent of total billed charges,,,,,,,,,145.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,145.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIOGRAPHY SIM2 4F 100CM,10570735,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,59.00,17.70,25.07,50.15,,36.46,,,percent of total billed charges,,,,,,,,service not payable,28.79,,,percent of total billed charges,,,29.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,44.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,29.5,,,percent of total billed charges,,,,,,,,service not payable,44.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,50.15,,,percent of total billed charges,,,27.14,,,percent of total billed charges,,,,,,,,,38.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,38.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB HIP G7 SZ H 62MM,10571257,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB HIP G7 SZ H 62MM,10571257,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CPM 11.5MMX40CM 125D,10571258,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CPM 11.5MMX40CM 125D,10571258,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 115X10.5MM,10571259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2486.00,745.80,964.57,2113.10,,,,,,,,,,,,,,,,,,,,964.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2113.10,,,percent of total billed charges,,,1118.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 115X10.5MM,10571259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,,,,,,,,,,,,service not payable,,,,,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB REV G7 SZ H 52MM,10571260,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11080.00,3324.00,4299.04,9418.0,,5429.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4653.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4299.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8310.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5540.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9418.0,,,percent of total billed charges,,,4986.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB REV G7 SZ H 52MM,10571260,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11080.00,3324.00,4653.60,9418.0,,5429.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4653.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5588.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4709.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8310.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5540.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8310.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9418.0,,,percent of total billed charges,,,5096.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT FIBERTAK DISPOSABLES STRT,10571266,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1502.00,450.60,582.78,1276.7,,,,,,,,,,,,,,,,,,,,582.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276.7,,,percent of total billed charges,,,675.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT FIBERTAK DISPOSABLES STRT,10571266,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,,,,,,,,,,,,service not payable,,,,,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE FIBERTAK KNOTLESS PRO2,10571267,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,487.00,146.10,188.96,413.95,,,,,,,,,,,,,,,,,,,,188.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.95,,,percent of total billed charges,,,219.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE FIBERTAK KNOTLESS PRO2,10571267,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,487.00,146.10,206.97,413.95,,,,,,,,,,,,,service not payable,,,,,,,245.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,206.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,365.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,243.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,365.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,413.95,,,percent of total billed charges,,,224.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTAP LH 4.5X36MM,10571584,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTAP LH 4.5X36MM,10571584,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEMORAL 130DEG 380X11MM X_04.037.158S X_DEPUY,10571585,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEMORAL 130DEG 380X11MM X_04.037.158S X_DEPUY,10571585,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
JUGGERSTITCH MENISCAL DEV STR,10571586,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2710.00,813.00,1051.48,2303.5,,,,,,,,,,,,,,,,,,,,1051.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1151.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2032.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1355.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2303.5,,,percent of total billed charges,,,1219.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JUGGERSTITCH MENISCAL DEV STR,10571586,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2710.00,813.00,1151.75,2303.5,,,,,,,,,,,,,service not payable,,,,,,,1366.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1151.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2032.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1355.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2032.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2303.5,,,percent of total billed charges,,,1246.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT INTRODUCER CROSSFIX DISP,10571587,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1230.00,369.00,477.24,1045.5,,,,,,,,,,,,,,,,,,,,477.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,922.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,615.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,,553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT INTRODUCER CROSSFIX DISP,10571587,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1230.00,369.00,522.75,1045.5,,,,,,,,,,,,,service not payable,,,,,,,620.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,522.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,922.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,615.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,922.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,,565.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUT ANCHOR C-SCREW 14.7X5.5MM,10571588,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1831.00,549.30,710.43,1556.35,,,,,,,,,,,,,,,,,,,,710.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1373.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,915.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1556.35,,,percent of total billed charges,,,823.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUT ANCHOR C-SCREW 14.7X5.5MM,10571588,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1831.00,549.30,778.17,1556.35,,,,,,,,,,,,,service not payable,,,,,,,923.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,778.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1373.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,915.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1373.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1556.35,,,percent of total billed charges,,,842.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB VANG PS 63/67MM,10571589,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB VANG PS 63/67MM,10571589,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2H 130D 38.1X54MM,10571590,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2268.00,680.40,879.98,1927.8,,,,,,,,,,,,,,,,,,,,879.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,963.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1701.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1134.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1927.8,,,percent of total billed charges,,,1020.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2H 130D 38.1X54MM,10571590,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2268.00,680.40,963.90,1927.8,,,,,,,,,,,,,service not payable,,,,,,,1143.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,963.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1701.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1134.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1701.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1927.8,,,percent of total billed charges,,,1043.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA SYM X3 X-LINK A27 8MM,10572446,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA SYM X3 X-LINK A27 8MM,10572446,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP PRESSFIT BI-MENTUM 57MM,10572447,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP PRESSFIT BI-MENTUM 57MM,10572447,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER BI -MENTUM PE 28/57,10572448,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER BI -MENTUM PE 28/57,10572448,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK T6 2.3 X 6MM,10572449,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1019.00,305.70,395.37,866.15,,,,,,,,,,,,,,,,,,,,395.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.15,,,percent of total billed charges,,,458.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK T6 2.3 X 6MM,10572449,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1019.00,305.70,433.07,866.15,,,,,,,,,,,,,service not payable,,,,,,,513.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,433.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,764.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,509.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,764.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,866.15,,,percent of total billed charges,,,468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 2.3X6MM,10572450,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 2.3X6MM,10572450,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NON-LCKG 2.3X8MM,10572451,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,801.00,240.30,310.79,680.85,,,,,,,,,,,,,,,,,,,,310.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.85,,,percent of total billed charges,,,360.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON-LCKG 2.3X8MM,10572451,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,801.00,240.30,340.43,680.85,,,,,,,,,,,,,service not payable,,,,,,,404.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,340.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,680.85,,,percent of total billed charges,,,368.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Tilt Table Evaluation.,10572481,CDM,0481,RC,93660,CPT,,,,,,outpatient,facility,,,1792.00,537.60,824.32,1775.0,,1107.46,,,percent of total billed charges,,,,,,,,,874.5,,,percent of total billed charges,,,903.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,1344.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,1344.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1523.2,,,percent of total billed charges,,,824.32,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Tilt Table Evaluation.,10572481,CDM,0481,RC,93660,CPT,05723,APC,,,,outpatient,facility,,,1792.00,537.60,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
Tilt Table Evaluation.,10572481,CDM,0481,RC,93660,CPT,80,EAPG,,,,outpatient,facility,,,1792.00,537.60,241.11,741.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,741.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,630.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,314.96,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,346.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Cannulation Thoracic Duct,10572549,CDM,0360,RC,38794,CPT,,,,,,outpatient,facility,,,1563.00,468.90,718.98,5463.36,,1563.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,5463.36,,,case rate,,,788.38,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,1172.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,1172.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1328.55,,,percent of total billed charges,,,718.98,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cannulation Thoracic Duct,10572549,CDM,0360,RC,38794,CPT,423,EAPG,,,,outpatient,facility,,,1563.00,468.90,994.94,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg Amphetamine Confirmation Ethanol,10572769,CDM,0300,RC,80325,CPT,,,,,,outpatient,facility,,,142.00,42.60,60.35,120.7,,87.76,,,percent of total billed charges,,,,,,,,service not payable,69.86,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,60.35,,,percent of total billed charges,,,,,,,,,106.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,71.0,,,percent of total billed charges,,,,,,,,service not payable,106.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,120.7,,,percent of total billed charges,,,65.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Chg Amphetamine Confirmation Ethanol,10572769,CDM,0300,RC,80325,CPT,2040,EAPG,,,,outpatient,facility,,,142.00,42.60,16.44,84.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,72.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,16.44,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,46.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Chg Amphetamine Confirmation Ethanol,10572769,CDM,0300,RC,G0480,HCPCS,,,,,,outpatient,facility,,,46.00,13.80,21.16,238.64,,28.43,,,percent of total billed charges,,,45.08,,,fee schedule,,,22.63,,,fee schedule,,,238.64,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,95.22,,,fee schedule,,,46.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",45.98,,,fee schedule,,,103.96,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,,,,,,,147.02,,,fee schedule,,,93.84,,,fee schedule,,,34.5,,,percent of total billed charges,,,45.08,,,fee schedule,,,46.0,,,fee schedule,,,45.98,,,fee schedule,,,172.90,,,fee schedule,,,45.08,,,fee schedule,,,34.5,,,percent of total billed charges,,,,,,,,,45.98,,,fee schedule,,,,,,,,,39.10,,,percent of total billed charges,,,21.16,,,percent of total billed charges,,,,,,,,,125.87,,,fee schedule,,,45.08,,,fee schedule,,,,,,,,,111.0,,,fee schedule,,,45.08,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,,,,,,
Chg Amphetamine Confirmation Ethanol,10572769,CDM,0300,RC,G0480,HCPCS,2041,EAPG,,,,outpatient,facility,,,46.00,13.80,46.0,141.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,120.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,46.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LENS TECNIS HYDROPHOBIC 5.00,10573167,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 5.00,10573167,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS HYDROPHOBIC 5.50D,10573168,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,845.00,253.50,327.86,718.25,,,,,,,,,,,,,,,,,,,,327.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.25,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS HYDROPHOBIC 5.50D,10573168,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,845.00,253.50,359.12,718.25,,,,,,,,,,,,,service not payable,,,,,,,426.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,633.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,633.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,718.25,,,percent of total billed charges,,,388.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 SZ10,10573169,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 SZ10,10573169,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PSN RT SZ9,10573170,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PSN RT SZ9,10573170,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURFACE KN RT 12MM,10573171,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURFACE KN RT 12MM,10573171,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 28MM 12 12/14,10573172,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1606.00,481.80,623.13,1365.10,,,,,,,,,,,,,,,,,,,,623.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.10,,,percent of total billed charges,,,722.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 28MM 12 12/14,10573172,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1606.00,481.80,682.55,1365.10,,,,,,,,,,,,,service not payable,,,,,,,810.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,682.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1204.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,803.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1204.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1365.10,,,percent of total billed charges,,,738.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT POLARCUP XPLE SZ57 28MM,10573173,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8508.00,2552.40,3301.10,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3301.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7231.80,,,percent of total billed charges,,,3828.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT POLARCUP XPLE SZ57 28MM,10573173,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8508.00,2552.40,3573.36,7231.80,,4168.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3573.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4291.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3615.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6381.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4254.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6381.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7231.80,,,percent of total billed charges,,,3913.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM REDAPT SZ 21H 300MM,10573174,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,26144.00,7843.20,10143.87,22222.40,,12810.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10980.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10143.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11111.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19608.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13072.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22222.40,,,percent of total billed charges,,,11764.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM REDAPT SZ 21H 300MM,10573174,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,26144.00,7843.20,10980.48,22222.40,,12810.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10980.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13187.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11111.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19608.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13072.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19608.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,22222.40,,,percent of total billed charges,,,12026.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL POLARCUP SZ57,10573175,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21243.00,6372.90,8242.28,18056.55,,10409.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8922.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8242.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9028.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15932.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10621.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18056.55,,,percent of total billed charges,,,9559.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL POLARCUP SZ57,10573175,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21243.00,6372.90,8922.06,18056.55,,10409.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8922.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10714.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9028.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15932.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10621.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15932.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18056.55,,,percent of total billed charges,,,9771.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEUROSTIMULATOR BRAIN PERCEPT,10573176,CDM,0278,RC,C1820,HCPCS,,,,,,inpatient,facility,,,48081.00,14424.30,18655.43,40868.85,,23559.69,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20194.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,18655.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20434.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,36060.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24040.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40868.85,,,percent of total billed charges,,,21636.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEUROSTIMULATOR BRAIN PERCEPT,10573176,CDM,0278,RC,C1820,HCPCS,,,,,,outpatient,facility,,,48081.00,14424.30,20194.02,40868.85,,23559.69,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20194.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,24252.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,20434.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,36060.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,24040.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,36060.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,40868.85,,,percent of total billed charges,,,22117.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROGRAMMER NEUROSTIM,10573177,CDM,0274,RC,C1787,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,,percent of total billed charges,,Paid in addition to inpatient services ,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROGRAMMER NEUROSTIM,10573177,CDM,0274,RC,C1787,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,,percent of total billed charges,,Paid in addition to outpatient services ,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ G RT,10573418,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ G RT,10573418,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ G XL 6-8X10MM,10573419,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ G XL 6-8X10MM,10573419,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN SH 125D 380X12MM,10573420,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN SH 125D 380X12MM,10573420,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT VAN-VE MLAP 10X71-75MM,10573421,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5508.00,1652.40,2137.10,4681.80,,2698.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2313.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2137.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2340.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4131.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2754.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4681.80,,,percent of total billed charges,,,2478.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT VAN-VE MLAP 10X71-75MM,10573421,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5508.00,1652.40,2313.36,4681.80,,2698.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2313.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2778.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2340.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4131.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2754.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4131.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4681.80,,,percent of total billed charges,,,2533.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING INSERT MLAP 10X79-83MM,10573422,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3541.00,1062.30,1373.91,3009.85,,,,,,,,,,,,,,,,,,,,1373.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.85,,,percent of total billed charges,,,1593.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING INSERT MLAP 10X79-83MM,10573422,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3541.00,1062.30,1504.92,3009.85,,,,,,,,,,,,,service not payable,,,,,,,1786.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3009.85,,,percent of total billed charges,,,1628.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING VIVACIT-E DM 28X44MM,10573423,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8851.00,2655.30,3434.19,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3434.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.35,,,percent of total billed charges,,,3982.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING VIVACIT-E DM 28X44MM,10573423,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8851.00,2655.30,3717.42,7523.35,,4336.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3717.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4464.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3761.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6638.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4425.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6638.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7523.35,,,percent of total billed charges,,,4071.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER ICD MOM X4 CRT-D,10573426,CDM,0275,RC,C1882,HCPCS,,,,,,inpatient,facility,,,51468.00,15440.40,19969.58,43747.80,,25219.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21616.56,,,percent of total billed charges,,Paid in addition to inpatient services ,19969.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21873.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38601.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25734.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43747.80,,,percent of total billed charges,,,23160.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER ICD MOM X4 CRT-D,10573426,CDM,0275,RC,C1882,HCPCS,,,,,,outpatient,facility,,,51468.00,15440.40,21616.56,43747.80,,25219.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21616.56,,,percent of total billed charges,,Paid in addition to outpatient services ,25960.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21873.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38601.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25734.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38601.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43747.80,,,percent of total billed charges,,,23675.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL SZ4 13MM,10573427,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3771.00,1131.30,1463.15,3205.35,,,,,,,,,,,,,,,,,,,,1463.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3205.35,,,percent of total billed charges,,,1696.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL SZ4 13MM,10573427,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3771.00,1131.30,1602.68,3205.35,,,,,,,,,,,,,service not payable,,,,,,,1902.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1602.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2828.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1885.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2828.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3205.35,,,percent of total billed charges,,,1734.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX HUM LO PLT RT 14H,10573428,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6082.00,1824.60,2359.82,5169.70,,2980.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2554.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2359.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2584.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4561.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3041.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5169.70,,,percent of total billed charges,,,2736.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX HUM LO PLT RT 14H,10573428,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6082.00,1824.60,2554.44,5169.70,,2980.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2554.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3067.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2584.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4561.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3041.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4561.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5169.70,,,percent of total billed charges,,,2797.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 NL 3.5X20MM,10573429,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 NL 3.5X20MM,10573429,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORT LCKG 3.5X48MM,10573430,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORT LCKG 3.5X48MM,10573430,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T15 MD LOCKING 3.5X34MM,10573431,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T15 MD LOCKING 3.5X34MM,10573431,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T15 MD LOCKING 3.5X36MM,10573432,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T15 MD LOCKING 3.5X36MM,10573432,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T15 MD LOCKING 3.5X38MM,10573433,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T15 MD LOCKING 3.5X38MM,10573433,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 NL 3.5X22MM,10573434,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 NL 3.5X22MM,10573434,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 NL 3.5X28MM,10573435,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 NL 3.5X28MM,10573435,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
T-PLATE 2.0MM 6 HOLE,10573438,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
T-PLATE 2.0MM 6 HOLE,10573438,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP 2.0 X 18MM,10573439,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP 2.0 X 18MM,10573439,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2.0 X 8MM,10573440,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2.0 X 8MM,10573440,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2.0 X 9MM,10573441,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2.0 X 9MM,10573441,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2.0 X 15MM,10573442,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2.0 X 15MM,10573442,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MESA 6.5 X 40MM,10573443,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MESA 6.5 X 40MM,10573443,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN HALF 3 X 100 X 25CM BLUE,10573444,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN HALF 3 X 100 X 25CM BLUE,10573444,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FIXED ST OZARK 4.0X12MM,10573446,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,930.00,279.00,360.84,790.5,,,,,,,,,,,,,,,,,,,,360.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FIXED ST OZARK 4.0X12MM,10573446,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,,,,,,,,,,,,service not payable,,,,,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARI ST OZARK 4.0X12MM,10573447,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,930.00,279.00,360.84,790.5,,,,,,,,,,,,,,,,,,,,360.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARI ST OZARK 4.0X12MM,10573447,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,930.00,279.00,395.25,790.5,,,,,,,,,,,,,service not payable,,,,,,,469.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,697.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,465.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,697.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,790.5,,,percent of total billed charges,,,427.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3 LEVEL OZARK 57MM,10573448,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3 LEVEL OZARK 57MM,10573448,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT VIKOS 11.5X14X5MM,10574609,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3642.00,1092.60,1413.10,3095.70,,,,,,,,,,,,,,,,,,,,1413.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1547.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2731.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1821.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3095.70,,,percent of total billed charges,,,1638.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT VIKOS 11.5X14X5MM,10574609,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3642.00,1092.60,1547.85,3095.70,,,,,,,,,,,,,service not payable,,,,,,,1837.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1547.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2731.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1821.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2731.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3095.70,,,percent of total billed charges,,,1675.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB H UNI SZ1 8MM LM/RL,10574610,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB H UNI SZ1 8MM LM/RL,10574610,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL 1 THORACIC 2.3X11MM,10574611,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,913.00,273.90,354.24,776.05,,,,,,,,,,,,,,,,,,,,354.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,,410.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL 1 THORACIC 2.3X11MM,10574611,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,913.00,273.90,388.02,776.05,,,,,,,,,,,,,service not payable,,,,,,,460.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,684.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,,419.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL 1 THORACIC 7H,10574612,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4232.00,1269.60,1642.02,3597.20,,,,,,,,,,,,,,,,,,,,1642.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1798.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3174.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2116.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3597.20,,,percent of total billed charges,,,1904.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL 1 THORACIC 7H,10574612,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4232.00,1269.60,1798.60,3597.20,,,,,,,,,,,,,service not payable,,,,,,,2134.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1798.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3174.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2116.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3174.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3597.20,,,percent of total billed charges,,,1946.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT SAC IFUSE 7.0X40MM,10574613,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11474.00,3442.20,4451.91,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4451.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9752.90,,,percent of total billed charges,,,5163.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT SAC IFUSE 7.0X40MM,10574613,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11474.00,3442.20,4819.08,9752.90,,5622.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4819.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5787.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4876.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8605.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5737.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8605.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9752.90,,,percent of total billed charges,,,5278.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIB PRESSFIT STR 20X60MM,10574614,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5892.00,1767.60,2286.10,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2286.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5008.20,,,percent of total billed charges,,,2651.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB PRESSFIT STR 20X60MM,10574614,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5892.00,1767.60,2474.64,5008.20,,2887.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2474.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2971.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2504.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4419.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2946.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4419.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5008.20,,,percent of total billed charges,,,2710.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM POST STAB SZ 5N LFT,10574616,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM POST STAB SZ 5N LFT,10574616,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR HEALICOIL K-LESS PK NST,10574617,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR HEALICOIL K-LESS PK NST,10574617,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR HEALICOIL K-LESS PK ST,10574618,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR HEALICOIL K-LESS PK ST,10574618,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STB 56X18MM,10574619,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6465.00,1939.50,2508.42,5495.25,,3167.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2715.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2508.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2747.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4848.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5495.25,,,percent of total billed charges,,,2909.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STB 56X18MM,10574619,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6465.00,1939.50,2715.30,5495.25,,3167.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2715.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3260.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2747.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4848.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4848.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5495.25,,,percent of total billed charges,,,2973.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TPRLC 16X152MM,10574620,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TPRLC 16X152MM,10574620,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 8X11X40 8DEG,10574621,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 8X11X40 8DEG,10574621,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RELINE TI 5.5X100MM,10574622,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,961.00,288.30,372.87,816.85,,,,,,,,,,,,,,,,,,,,372.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,408.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,720.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,480.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.85,,,percent of total billed charges,,,432.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RELINE TI 5.5X100MM,10574622,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,961.00,288.30,408.43,816.85,,,,,,,,,,,,,service not payable,,,,,,,484.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,408.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,720.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,480.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,720.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,816.85,,,percent of total billed charges,,,442.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR CROSS 50MM,10574623,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR CROSS 50MM,10574623,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN LP BLUNT 4.0X44MM,10574624,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN LP BLUNT 4.0X44MM,10574624,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH INDIGO 12FR XTORQ 100CM,10574626,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,22325.00,6697.50,9488.13,18976.25,,13796.85,,,percent of total billed charges,,,,,,,,service not payable,10894.6,,,percent of total billed charges,,,11260.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9488.13,,,percent of total billed charges,,,,,,,,,16743.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11162.5,,,percent of total billed charges,,,,,,,,service not payable,16743.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18976.25,,,percent of total billed charges,,,10269.5,,,percent of total billed charges,,,,,,,,,14511.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,14511.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG BONE ALPS PRX HUM 3.2X34MM,10574794,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG BONE ALPS PRX HUM 3.2X34MM,10574794,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL LOCK 3.5X50MM,10574795,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,721.00,216.30,279.75,612.85,,,,,,,,,,,,,,,,,,,,279.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.85,,,percent of total billed charges,,,324.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL LOCK 3.5X50MM,10574795,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,721.00,216.30,306.43,612.85,,,,,,,,,,,,,service not payable,,,,,,,363.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,306.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,540.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,360.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,540.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,612.85,,,percent of total billed charges,,,331.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T5 1.7X5MM,10574796,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1015.00,304.50,393.82,862.75,,,,,,,,,,,,,,,,,,,,393.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T5 1.7X5MM,10574796,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1015.00,304.50,431.38,862.75,,,,,,,,,,,,,service not payable,,,,,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,761.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T5 1.7X6MM,10574797,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1015.00,304.50,393.82,862.75,,,,,,,,,,,,,,,,,,,,393.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T5 1.7X6MM,10574797,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1015.00,304.50,431.38,862.75,,,,,,,,,,,,,service not payable,,,,,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,761.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG T5 1.7X7MM,10574798,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1015.00,304.50,393.82,862.75,,,,,,,,,,,,,,,,,,,,393.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG T5 1.7X7MM,10574798,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1015.00,304.50,431.38,862.75,,,,,,,,,,,,,service not payable,,,,,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,761.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CEMENTRALIZER PRIM RE 210TH,10574802,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMENTRALIZER PRIM RE 210TH,10574802,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS CEM SZ5N LT,10574803,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5087.00,1526.10,1973.76,4323.95,,2492.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2136.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1973.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2161.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3815.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2543.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4323.95,,,percent of total billed charges,,,2289.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS CEM SZ5N LT,10574803,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5087.00,1526.10,2136.54,4323.95,,2492.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2136.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2565.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2161.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3815.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2543.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3815.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4323.95,,,percent of total billed charges,,,2340.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
OT 29240 Strapping Shoulder,10575141,CDM,0430,RC,29240,CPT,,,,,GO  ,outpatient,facility,,,235.00,70.50,108.10,260.0,,145.23,,,percent of total billed charges,,,,,,,,,114.68,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,176.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,176.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.75,,,percent of total billed charges,,,108.10,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
OT 29240 Strapping Shoulder,10575141,CDM,0430,RC,29240,CPT,05734,APC,,,GO  ,outpatient,facility,,,235.00,70.50,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
OT 29240 Strapping Shoulder,10575141,CDM,0430,RC,29240,CPT,40,EAPG,,,GO  ,outpatient,facility,,,235.00,70.50,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
KIT CVC 7FR 2 LUMEN 16CM X_AK42702-CDC X_ARROW,1057520,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,185.40,,,percent of total billed charges,,,,,,,,service not payable,146.40,,,percent of total billed charges,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CVC 7FR 2 LUMEN 16CM X_AK42702-SK X_ARROW I,1057521,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,185.40,,,percent of total billed charges,,,,,,,,service not payable,146.40,,,percent of total billed charges,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 21.0,10575245,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 21.0,10575245,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 19.0,10575246,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 19.0,10575246,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 18.5D,10575247,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 18.5D,10575247,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM GLOBAL UNITE 12MM 0,10575248,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM GLOBAL UNITE 12MM 0,10575248,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD GLBL UNITE ECC 48X15 MM,10575249,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD GLBL UNITE ECC 48X15 MM,10575249,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER PALI 14.5FX19 X_8888145058 X_KENDALL,1057525,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,2499.00,749.70,1062.08,2124.15,,1544.38,,,percent of total billed charges,,,,,,,,service not payable,1219.51,,,percent of total billed charges,,,1260.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1062.08,,,percent of total billed charges,,,,,,,,,1874.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1249.5,,,percent of total billed charges,,,,,,,,service not payable,1874.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2124.15,,,percent of total billed charges,,,1149.54,,,percent of total billed charges,,,,,,,,,1624.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1624.35,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK EVOS 3.5 X 13,10575250,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK EVOS 3.5 X 13,10575250,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK EVOS 3.5 X 15,10575251,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK EVOS 3.5 X 15,10575251,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB LAT DIST 9H,10575252,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3416.00,1024.80,1325.41,2903.60,,,,,,,,,,,,,,,,,,,,1325.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1451.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2562.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1708.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2903.60,,,percent of total billed charges,,,1537.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB LAT DIST 9H,10575252,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3416.00,1024.80,1451.8,2903.60,,,,,,,,,,,,,service not payable,,,,,,,1723.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1451.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2562.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1708.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2562.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2903.60,,,percent of total billed charges,,,1571.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD MOD 28MM 6MM NECK,10575253,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD MOD 28MM 6MM NECK,10575253,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 12MM 79/83MM,10575254,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 12MM 79/83MM,10575254,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT VAN-VE MLAP 10MM 63/67M,10575255,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT VAN-VE MLAP 10MM 63/67M,10575255,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER DIST STEM 12MM,10575256,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER DIST STEM 12MM,10575256,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 14MM 79/83M,10575257,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 14MM 79/83M,10575257,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO FX 9MM 130,10575258,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO FX 9MM 130,10575258,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE BONE KIRSCHNER 0.028 X 4,10575259,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,140.00,42.00,54.32,119.0,,,,,,,,,,,,,,,,,,,,54.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,,63.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE BONE KIRSCHNER 0.028 X 4,10575259,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,140.00,42.00,59.5,119.0,,,,,,,,,,,,,service not payable,,,,,,,70.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,105.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,,64.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM RT MD DST 4H 2.7/3.5,10575260,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5540.00,1662.00,2149.52,4709.0,,2714.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2326.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.0,,,percent of total billed charges,,,2493.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM RT MD DST 4H 2.7/3.5,10575260,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5540.00,1662.00,2326.80,4709.0,,2714.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2326.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.0,,,percent of total billed charges,,,2548.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM RT LA DST 2H 2.7/3.5,10575261,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5369.00,1610.70,2083.17,4563.65,,2630.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2254.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2083.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4026.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2684.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.65,,,percent of total billed charges,,,2416.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM RT LA DST 2H 2.7/3.5,10575261,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5369.00,1610.70,2254.98,4563.65,,2630.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2254.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2708.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2281.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4026.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2684.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4026.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4563.65,,,percent of total billed charges,,,2469.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LK ST 2.7X52MM,10575262,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1122.00,336.60,435.34,953.70,,,,,,,,,,,,,,,,,,,,435.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,953.70,,,percent of total billed charges,,,504.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LK ST 2.7X52MM,10575262,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1122.00,336.60,476.85,953.70,,,,,,,,,,,,,service not payable,,,,,,,565.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,841.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,953.70,,,percent of total billed charges,,,516.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LK ST 2.7X54MM,10575263,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1122.00,336.60,435.34,953.70,,,,,,,,,,,,,,,,,,,,435.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,953.70,,,percent of total billed charges,,,504.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LK ST 2.7X54MM,10575263,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1122.00,336.60,476.85,953.70,,,,,,,,,,,,,service not payable,,,,,,,565.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,841.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,953.70,,,percent of total billed charges,,,516.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LK ST 2.7X56MM,10575264,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1122.00,336.60,435.34,953.70,,,,,,,,,,,,,,,,,,,,435.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,953.70,,,percent of total billed charges,,,504.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LK ST 2.7X56MM,10575264,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1122.00,336.60,476.85,953.70,,,,,,,,,,,,,service not payable,,,,,,,565.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,841.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,953.70,,,percent of total billed charges,,,516.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LK ST 2.7X60MM,10575265,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1122.00,336.60,435.34,953.70,,,,,,,,,,,,,,,,,,,,435.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,953.70,,,percent of total billed charges,,,504.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LK ST 2.7X60MM,10575265,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1122.00,336.60,476.85,953.70,,,,,,,,,,,,,service not payable,,,,,,,565.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,841.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,953.70,,,percent of total billed charges,,,516.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Implanted Port Location,10576529,CDM,0761,RC,36591,CPT,,,,,,outpatient,facility,,,377.00,113.10,118.0,320.45,,232.99,,,percent of total billed charges,,,,,,,,,183.98,,,percent of total billed charges,,,190.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.22,,,percent of total billed charges,,,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,188.5,,,percent of total billed charges,,,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,320.45,,,percent of total billed charges,,,173.42,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Implanted Port Location,10576529,CDM,0761,RC,36591,CPT,05734,APC,,,,outpatient,facility,,,377.00,113.10,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
Implanted Port Location,10576529,CDM,0761,RC,36591,CPT,494,EAPG,,,,outpatient,facility,,,377.00,113.10,109.28,553.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,470.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,354.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,390.10,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PICC Location,10576531,CDM,0761,RC,36592,CPT,,,,,,outpatient,facility,,,377.00,113.10,118.0,320.45,,232.99,,,percent of total billed charges,,,,,,,,,183.98,,,percent of total billed charges,,,190.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.22,,,percent of total billed charges,,,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,188.5,,,percent of total billed charges,,,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,320.45,,,percent of total billed charges,,,173.42,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PICC Location,10576531,CDM,0761,RC,36592,CPT,05734,APC,,,,outpatient,facility,,,377.00,113.10,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
PICC Location,10576531,CDM,0761,RC,36592,CPT,494,EAPG,,,,outpatient,facility,,,377.00,113.10,109.28,553.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,470.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,109.28,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,354.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,390.10,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CORT SS ST FT SD 2.7X44,10576540,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,152.00,45.60,58.98,129.20,,,,,,,,,,,,,,,,,,,,58.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.20,,,percent of total billed charges,,,68.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SS ST FT SD 2.7X44,10576540,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,152.00,45.60,64.60,129.20,,,,,,,,,,,,,service not payable,,,,,,,76.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,64.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,76.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,129.20,,,percent of total billed charges,,,69.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SS ST FT SD 2.7X60,10576541,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,122.00,36.60,47.34,103.7,,,,,,,,,,,,,,,,,,,,47.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,91.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.7,,,percent of total billed charges,,,54.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SS ST FT SD 2.7X60,10576541,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,122.00,36.60,51.85,103.7,,,,,,,,,,,,,service not payable,,,,,,,61.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,51.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,91.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,61.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,91.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,103.7,,,percent of total billed charges,,,56.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG ST 5.0X46MM,10576542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,423.00,126.90,164.12,359.55,,,,,,,,,,,,,,,,,,,,164.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,317.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.55,,,percent of total billed charges,,,190.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG ST 5.0X46MM,10576542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,423.00,126.90,179.78,359.55,,,,,,,,,,,,,service not payable,,,,,,,213.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,317.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,317.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,359.55,,,percent of total billed charges,,,194.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG ST 5.0X42MM,10576543,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,338.00,101.40,131.14,287.30,,,,,,,,,,,,,,,,,,,,131.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,253.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,169.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.30,,,percent of total billed charges,,,152.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG ST 5.0X42MM,10576543,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,338.00,101.40,143.65,287.30,,,,,,,,,,,,,service not payable,,,,,,,170.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,143.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,253.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,169.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,253.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,287.30,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FEM NECK SYS 75MM,10576544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,349.00,104.70,135.41,296.65,,,,,,,,,,,,,,,,,,,,135.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,157.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FEM NECK SYS 75MM,10576544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,349.00,104.70,148.32,296.65,,,,,,,,,,,,,service not payable,,,,,,,176.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,148.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,261.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,174.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,261.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,296.65,,,percent of total billed charges,,,160.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BOLT FEM NECK SYST STERILE 75M,10576545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,444.00,133.20,172.27,377.40,,,,,,,,,,,,,,,,,,,,172.27,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,333.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,222.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.40,,,percent of total billed charges,,,199.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOLT FEM NECK SYST STERILE 75M,10576545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,444.00,133.20,188.70,377.40,,,,,,,,,,,,,service not payable,,,,,,,223.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,188.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,333.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,222.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,333.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,377.40,,,percent of total billed charges,,,204.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert defib pulse generator w/existing dual leads,10576718,CDM,0481,RC,33230,CPT,,,,,,outpatient,facility,,,59139.00,17741.70,4917.20,50947.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,29829.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43305.0,,,case rate,,,,,,,,,44354.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50947.0,,,case rate,,,,,,,,,44354.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50268.15,,,percent of total billed charges,,,27203.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
Insert defib pulse generator w/existing dual leads,10576718,CDM,0481,RC,33230,CPT,05231,APC,,,,outpatient,facility,,,59139.00,17741.70,20646.60,49437.86,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,45281.58,,,fee schedule,,,20646.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",21900.60,,,fee schedule,,,49437.86,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,44625.33,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,20646.60,,,fee schedule,,,21900.60,,,fee schedule,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,20646.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",21900.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,,,,,,,21471.18,,,fee schedule,,,,,,,,,21685.55,,,fee schedule,,,,,,,,
Insert defib pulse generator w/existing dual leads,10576718,CDM,0481,RC,33230,CPT,97,EAPG,,,,outpatient,facility,,,59139.00,17741.70,32245.61,50588.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50588.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,42999.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,32245.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,42921.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,47214.18,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Revasc  endovasculasc iliac artery w/angioplasty a,10576721,CDM,0481,RC,37221,CPT,,,,,,outpatient,facility,,,14752.00,4425.60,5463.36,18583.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,7440.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12539.20,,,percent of total billed charges,,,6785.92,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Revasc  endovasculasc iliac artery w/angioplasty a,10576721,CDM,0481,RC,37221,CPT,05193,APC,,,,outpatient,facility,,,14752.00,4425.60,10431.35,24977.68,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22877.78,,,fee schedule,,,10431.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",11081.84,,,fee schedule,,,24977.68,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,22546.22,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,10431.35,,,fee schedule,,,11081.84,,,fee schedule,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10431.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",11081.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,,,,,,,10864.55,,,fee schedule,,,,,,,,,10972.86,,,fee schedule,,,,,,,,
Revasc  endovasculasc iliac artery w/angioplasty a,10576721,CDM,0481,RC,37221,CPT,85,EAPG,,,,outpatient,facility,,,14752.00,4425.60,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14752.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14752.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14752.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Transluminal Balloon Angioplasty Non Lower Extrem,10576724,CDM,0481,RC,37246,CPT,,,,,,outpatient,facility,,,15272.00,4581.60,7025.12,12981.20,,11611.47,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,8909.33,,,case rate,,,7703.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,11454.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,11454.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12981.20,,,percent of total billed charges,,,7025.12,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Transluminal Balloon Angioplasty Non Lower Extrem,10576724,CDM,0481,RC,37246,CPT,05192,APC,,,,outpatient,facility,,,15272.00,4581.60,5244.41,12557.62,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,11501.89,,,fee schedule,,,5244.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5576.92,,,fee schedule,,,12557.62,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,11335.20,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,5244.41,,,fee schedule,,,5576.92,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,5244.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5576.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,5522.02,,,fee schedule,,,,,,,,
Transluminal Balloon Angioplasty Non Lower Extrem,10576724,CDM,0481,RC,37246,CPT,77,EAPG,,,,outpatient,facility,,,15272.00,4581.60,5360.09,12010.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12010.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,10209.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6296.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,6925.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PESSARY RING W SUPPORT 5,10577275,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPPORT 5,10577275,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,139.40,,,,,,,,,,,,,service not payable,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FORMULA NUTRAMIGEN ENFLORA LGG,10577276,CDM,0272,RC,B4161,HCPCS,,,,,,outpatient,facility,,,168.00,50.40,71.40,142.80,,103.82,,,percent of total billed charges,,,,,,,,service not payable,81.98,,,percent of total billed charges,,,84.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,84.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,84.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,71.40,,,percent of total billed charges,,,,,,,,,126.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,84.0,,,percent of total billed charges,,,,,,,,service not payable,126.0,,,percent of total billed charges,,,,,,,,service not payable,75.60,,,fee schedule,,,,,,,,,142.80,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,109.2,,,percent of total billed charges,,,84.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
FORMULA NUTRAMIGEN ENFLORA LGG,10577276,CDM,0272,RC,B4161,HCPCS,498,EAPG,,,,outpatient,facility,,,168.00,50.40,48.98,896.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,762.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,53.88,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT TENDON GRACILIS FF,10577277,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4454.00,1336.20,1728.15,3785.90,,,,,,,,,,,,,,,,,,,,1728.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1892.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3340.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2227.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3785.90,,,percent of total billed charges,,,2004.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TENDON GRACILIS FF,10577277,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4454.00,1336.20,1892.95,3785.90,,,,,,,,,,,,,service not payable,,,,,,,2246.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1892.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3340.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2227.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3340.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3785.90,,,percent of total billed charges,,,2048.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD LT SZ 8,10577286,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD LT SZ 8,10577286,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SF 11MM LT,10577287,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SF 11MM LT,10577287,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL 12X125MM,10577288,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL 12X125MM,10577288,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER DISTAL 10MM,10577289,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER DISTAL 10MM,10577289,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REVERSED SHOULD 39X9MM,10577290,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REVERSED SHOULD 39X9MM,10577290,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SUR PSN 11MM LT,10577291,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SUR PSN 11MM LT,10577291,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ8 LT,10577292,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ8 LT,10577292,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIBIA PSN SZE LT 5DEG,10577293,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIBIA PSN SZE LT 5DEG,10577293,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL BONE EL TI GOLD3 3.0X450M,10577294,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2184.00,655.20,847.39,1856.40,,,,,,,,,,,,,,,,,,,,847.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,928.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1638.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1092.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856.40,,,percent of total billed charges,,,982.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL BONE EL TI GOLD3 3.0X450M,10577294,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2184.00,655.20,928.20,1856.40,,,,,,,,,,,,,service not payable,,,,,,,1101.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,928.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1638.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1092.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1638.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1856.40,,,percent of total billed charges,,,1004.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BRD LCK 8H 2.7X73MM,10577295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3782.00,1134.60,1467.42,3214.70,,,,,,,,,,,,,,,,,,,,1467.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1607.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2836.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3214.70,,,percent of total billed charges,,,1701.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BRD LCK 8H 2.7X73MM,10577295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3782.00,1134.60,1607.35,3214.70,,,,,,,,,,,,,service not payable,,,,,,,1907.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1607.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2836.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1891.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2836.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3214.70,,,percent of total billed charges,,,1739.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE FIXED ANG 4.35X14MM,10577297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,456.00,136.80,176.93,387.60,,,,,,,,,,,,,,,,,,,,176.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,342.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,228.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.60,,,percent of total billed charges,,,205.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE FIXED ANG 4.35X14MM,10577297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,456.00,136.80,193.80,387.60,,,,,,,,,,,,,service not payable,,,,,,,230.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,193.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,342.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,228.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,342.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,387.60,,,percent of total billed charges,,,209.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PERI SLFTAP 2.7 3.5X26MM,10577299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERI SLFTAP 2.7 3.5X26MM,10577299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA POLY PSN 35MM,10577301,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA POLY PSN 35MM,10577301,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRODUCER 9FR 25CM X_CLS-2509 X_CARDIO MED,10577593,CDM,0278,RC,C1894,HCPCS,,,,,,inpatient,facility,,,384.00,115.20,148.99,326.40,,,,,,,,,,,,,,,,,,,,148.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,172.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHEATH INTRODUCER 9FR 25CM X_CLS-2509 X_CARDIO MED,10577593,CDM,0278,RC,C1894,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,,,,,,,,,,,,service not payable,,,,,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT GELSOFT 22X11MM X_632211 X_TERUMO MEDICAL,10577594,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2318.00,695.40,899.38,1970.3,,,,,,,,,,,,,,,,,,,,899.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,985.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1159.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.3,,,percent of total billed charges,,,1043.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT GELSOFT 22X11MM X_632211 X_TERUMO MEDICAL,10577594,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2318.00,695.40,985.15,1970.3,,,,,,,,,,,,,service not payable,,,,,,,1169.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,985.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1738.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1159.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1738.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1970.3,,,percent of total billed charges,,,1066.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 22.5D,10577757,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 22.5D,10577757,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 22.0D,10577758,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 22.0D,10577758,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 21.5D,10577759,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 21.5D,10577759,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 20.0D,10577760,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 20.0D,10577760,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 19.0D,10577761,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 19.0D,10577761,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 19.5D,10577762,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 19.5D,10577762,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE CERTAS PLUS SMALL,10577985,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,15201.00,4560.30,5897.99,12920.85,,7448.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6384.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5897.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6460.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11400.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7600.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12920.85,,,percent of total billed charges,,,6840.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE CERTAS PLUS SMALL,10577985,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,15201.00,4560.30,6384.42,12920.85,,7448.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6384.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7667.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6460.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11400.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7600.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11400.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12920.85,,,percent of total billed charges,,,6992.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK TI 3.5X10MM,10577987,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK TI 3.5X10MM,10577987,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT MINI HEX 2.0X24MM,10577989,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT MINI HEX 2.0X24MM,10577989,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SM HEX 2.7X60MM,10577990,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SM HEX 2.7X60MM,10577990,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SM HEX 2.7X70MM,10577991,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SM HEX 2.7X70MM,10577991,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER SM 7.0MM,10577992,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SM 7.0MM,10577992,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 45,10577993,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,6066.00,1819.80,2353.61,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2353.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5156.10,,,percent of total billed charges,,,2729.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 45,10577993,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2547.72,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC RT 6-9 16MM,10577999,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC RT 6-9 16MM,10577999,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING DM 28X40MM SZD,10578000,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING DM 28X40MM SZD,10578000,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 5X30MM,10578001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 5X30MM,10578001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 79-83X12MM,10578002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 79-83X12MM,10578002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR PSN SZ8 RT,10578003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR PSN SZ8 RT,10578003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL 1 8H T 3MM,10578004,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3887.00,1166.10,1508.16,3303.95,,,,,,,,,,,,,,,,,,,,1508.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1651.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2915.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1943.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3303.95,,,percent of total billed charges,,,1749.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL 1 8H T 3MM,10578004,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3887.00,1166.10,1651.97,3303.95,,,,,,,,,,,,,service not payable,,,,,,,1960.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1651.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2915.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1943.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2915.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3303.95,,,percent of total billed charges,,,1788.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL 1 26H T 3MM,10578005,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5134.00,1540.20,1991.99,4363.90,,2515.66,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2156.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1991.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2181.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2567.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4363.90,,,percent of total billed charges,,,2310.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL 1 26H T 3MM,10578005,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5134.00,1540.20,2156.28,4363.90,,2515.66,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2156.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2589.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2181.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3850.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2567.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3850.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4363.90,,,percent of total billed charges,,,2361.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE NCB PP PROX FEM L 324MM,10578006,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4213.00,1263.90,1634.64,3581.05,,,,,,,,,,,,,,,,,,,,1634.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3159.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3581.05,,,percent of total billed charges,,,1895.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE NCB PP PROX FEM L 324MM,10578006,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4213.00,1263.90,1790.52,3581.05,,,,,,,,,,,,,service not payable,,,,,,,2125.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1790.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3159.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3159.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3581.05,,,percent of total billed charges,,,1937.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CNC PL 4.0X26MM X_73825326 X_SMITH NEPHEW,10578008,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,178.00,53.40,69.06,151.30,,,,,,,,,,,,,,,,,,,,69.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,,80.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CNC PL 4.0X26MM X_73825326 X_SMITH NEPHEW,10578008,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,178.00,53.40,75.65,151.30,,,,,,,,,,,,,service not payable,,,,,,,89.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,75.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,133.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,89.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,133.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,,81.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Newborn Scr NE Spinal Muscular Atrophy,10578147,CDM,0310,RC,81329,CPT,,,,,,outpatient,facility,,,12.00,3.60,5.52,285.71,,7.42,,,percent of total billed charges,,,11.76,,,fee schedule,,,5.90,,,fee schedule,,,285.71,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,24.84,,,fee schedule,,,12.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.0,,,fee schedule,,,27.12,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,,176.09,,,fee schedule,,,24.48,,,fee schedule,,,9.0,,,percent of total billed charges,,,11.76,,,fee schedule,,,12.0,,,fee schedule,,,12.0,,,fee schedule,,,207.09,,,fee schedule,,,11.76,,,fee schedule,,,9.0,,,percent of total billed charges,,,12.0,,,fee schedule,,,12.0,,,fee schedule,,,,,,,,,10.20,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,150.70,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,132.89,,,fee schedule,,,11.76,,,fee schedule,,,,,,,,,11.76,,,fee schedule,,,,,,,,
Newborn Scr NE Spinal Muscular Atrophy,10578147,CDM,0310,RC,81329,CPT,386,EAPG,,,,outpatient,facility,,,12.00,3.60,12.0,496.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,422.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,12.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,117.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,128.90,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ROD COMPR SCREW-IN VERSION,10578295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,817.00,245.10,317.00,694.45,,,,,,,,,,,,,,,,,,,,317.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,612.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,408.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.45,,,percent of total billed charges,,,367.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD COMPR SCREW-IN VERSION,10578295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,817.00,245.10,347.22,694.45,,,,,,,,,,,,,service not payable,,,,,,,412.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,347.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,612.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,408.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,612.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,694.45,,,percent of total billed charges,,,375.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATALLA TRIATHLON ASYM 11MM,10578296,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATALLA TRIATHLON ASYM 11MM,10578296,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ADV 35D ANG 0.018 180CM,10578297,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1175.00,352.50,499.38,998.75,,726.15,,,percent of total billed charges,,,,,,,,service not payable,573.40,,,percent of total billed charges,,,592.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,499.38,,,percent of total billed charges,,,,,,,,,881.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,587.5,,,percent of total billed charges,,,,,,,,service not payable,881.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,540.5,,,percent of total billed charges,,,,,,,,,763.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,763.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ADV 35D ANG 0.018 300CM,10578298,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1322.00,396.60,561.85,1123.7,,817.0,,,percent of total billed charges,,,,,,,,service not payable,645.14,,,percent of total billed charges,,,666.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,561.85,,,percent of total billed charges,,,,,,,,,991.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,661.0,,,percent of total billed charges,,,,,,,,service not payable,991.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1123.7,,,percent of total billed charges,,,608.12,,,percent of total billed charges,,,,,,,,,859.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,859.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ADV 35D ANG 0.014 180CM,10578299,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1203.00,360.90,511.27,1022.55,,743.45,,,percent of total billed charges,,,,,,,,service not payable,587.06,,,percent of total billed charges,,,606.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,511.27,,,percent of total billed charges,,,,,,,,,902.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,601.5,,,percent of total billed charges,,,,,,,,service not payable,902.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1022.55,,,percent of total billed charges,,,553.38,,,percent of total billed charges,,,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,781.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE ADV 35D ANG 0.014 300CM,10578300,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1355.00,406.50,575.88,1151.75,,837.39,,,percent of total billed charges,,,,,,,,service not payable,661.24,,,percent of total billed charges,,,683.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,575.88,,,percent of total billed charges,,,,,,,,,1016.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,677.5,,,percent of total billed charges,,,,,,,,service not payable,1016.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1151.75,,,percent of total billed charges,,,623.30,,,percent of total billed charges,,,,,,,,,880.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,880.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/4 TUBULAR 4H 39MM,10578301,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,452.00,135.60,175.38,384.20,,,,,,,,,,,,,,,,,,,,175.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,339.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,226.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.20,,,percent of total billed charges,,,203.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/4 TUBULAR 4H 39MM,10578301,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,452.00,135.60,192.10,384.20,,,,,,,,,,,,,service not payable,,,,,,,227.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,192.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,339.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,226.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,339.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,384.20,,,percent of total billed charges,,,207.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN BIODUR 108 4X60MM,10578302,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BIODUR 108 4X60MM,10578302,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER SCREW CANN 3.5-4MM,10578303,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SCREW CANN 3.5-4MM,10578303,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X36MM,10578304,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X36MM,10578304,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X34MM,10578305,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X34MM,10578305,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ F LT 5-7X10MM,10578307,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ F LT 5-7X10MM,10578307,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA NEXGEN CR-FLEX 32MM,10578308,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA NEXGEN CR-FLEX 32MM,10578308,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X36MM,10578309,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X36MM,10578309,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT CATH REV PROMETRA,10578314,CDM,0272,RC,C1755,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,337.43,,,percent of total billed charges,,,,,,,,service not payable,266.45,,,percent of total billed charges,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 5X35MM,10578316,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 5X35MM,10578316,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 3 4.5X40MM,10578317,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 3 4.5X40MM,10578317,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAX 5.5X35MM SERRATO,10578318,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3213.00,963.90,1246.64,2731.05,,,,,,,,,,,,,,,,,,,,1246.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2731.05,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAX 5.5X35MM SERRATO,10578318,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3213.00,963.90,1365.52,2731.05,,,,,,,,,,,,,service not payable,,,,,,,1620.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1365.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2409.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2731.05,,,percent of total billed charges,,,1477.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM CERAMIC 32MM 5,10578319,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8423.00,2526.90,3268.12,7159.55,,4127.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3537.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3268.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3579.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6317.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4211.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7159.55,,,percent of total billed charges,,,3790.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM CERAMIC 32MM 5,10578319,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8423.00,2526.90,3537.66,7159.55,,4127.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3537.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4248.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3579.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6317.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4211.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6317.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7159.55,,,percent of total billed charges,,,3874.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP LT 2.4-2.7X52MM,10578320,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,779.00,233.70,302.25,662.15,,,,,,,,,,,,,,,,,,,,302.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,584.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,389.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.15,,,percent of total billed charges,,,350.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP LT 2.4-2.7X52MM,10578320,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,779.00,233.70,331.07,662.15,,,,,,,,,,,,,service not payable,,,,,,,392.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,331.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,584.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,389.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,584.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,662.15,,,percent of total billed charges,,,358.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI 20X2.5MM,10578322,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,591.00,177.30,229.31,502.35,,,,,,,,,,,,,,,,,,,,229.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,443.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,295.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.35,,,percent of total billed charges,,,265.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI 20X2.5MM,10578322,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,591.00,177.30,251.17,502.35,,,,,,,,,,,,,service not payable,,,,,,,298.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,251.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,443.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,295.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,443.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,502.35,,,percent of total billed charges,,,271.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 8.0X85MM,10578323,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2238.00,671.40,868.34,1902.3,,,,,,,,,,,,,,,,,,,,868.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1678.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1119.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1902.3,,,percent of total billed charges,,,1007.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 8.0X85MM,10578323,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2238.00,671.40,951.15,1902.3,,,,,,,,,,,,,service not payable,,,,,,,1128.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,951.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1678.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1119.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1678.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1902.3,,,percent of total billed charges,,,1029.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SET ARROW INTRODUCER SHEATH 6F,10578539,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,67.00,20.10,28.48,56.95,,41.41,,,percent of total billed charges,,,,,,,,service not payable,32.70,,,percent of total billed charges,,,33.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,28.48,,,percent of total billed charges,,,,,,,,,50.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,33.5,,,percent of total billed charges,,,,,,,,service not payable,50.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,56.95,,,percent of total billed charges,,,30.82,,,percent of total billed charges,,,,,,,,,43.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,43.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH TEMPO 0.038IN X 5F 65CM,10578540,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,149.00,44.70,63.33,126.65,,92.08,,,percent of total billed charges,,,,,,,,service not payable,72.71,,,percent of total billed charges,,,75.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,63.33,,,percent of total billed charges,,,,,,,,,111.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.5,,,percent of total billed charges,,,,,,,,service not payable,111.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,96.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,96.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIER PTCA SION STR BLK 300CM,10578541,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,1435.61,,,percent of total billed charges,,,,,,,,service not payable,1133.62,,,percent of total billed charges,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1509.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIER LUNDERQUIST 30X4X15CM,10578542,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,531.00,159.30,225.68,451.35,,328.16,,,percent of total billed charges,,,,,,,,service not payable,259.13,,,percent of total billed charges,,,267.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,225.68,,,percent of total billed charges,,,,,,,,,398.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,265.5,,,percent of total billed charges,,,,,,,,service not payable,398.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,451.35,,,percent of total billed charges,,,244.26,,,percent of total billed charges,,,,,,,,,345.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,345.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH UNIFUSE 5F 135X40CM,10578543,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,558.00,167.40,237.15,474.30,,344.84,,,percent of total billed charges,,,,,,,,service not payable,272.30,,,percent of total billed charges,,,281.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,237.15,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,418.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,474.30,,,percent of total billed charges,,,256.68,,,percent of total billed charges,,,,,,,,,362.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,362.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SUPERION IDS-8MM,10578546,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SUPERION IDS-8MM,10578546,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS SUPERION IDS-8MM,10578547,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS SUPERION IDS-8MM,10578547,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SUPERION IDS-10MM,10578548,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SUPERION IDS-10MM,10578548,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SUPERION IDS 10MM,10578549,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SUPERION IDS 10MM,10578549,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SUPERION IDS-12MM,10578550,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SUPERION IDS-12MM,10578550,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS SUPERION IDS-12MM,10578551,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS SUPERION IDS-12MM,10578551,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SUPERION IDS-14MM,10578552,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SUPERION IDS-14MM,10578552,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS SUPERION IDS-14MM,10578553,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS SUPERION IDS-14MM,10578553,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SUPERION IDS-16MM,10578554,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SUPERION IDS-16MM,10578554,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS SUPERION IDS-16MM,10578555,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,19669.00,5900.70,7631.57,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7631.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16718.65,,,percent of total billed charges,,,8851.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS SUPERION IDS-16MM,10578555,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,19669.00,5900.70,8260.98,16718.65,,9637.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8260.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9921.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8359.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9834.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14751.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16718.65,,,percent of total billed charges,,,9047.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM C FEM AMT SZ5 HI,10578558,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM C FEM AMT SZ5 HI,10578558,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Ligate  divide  and/or exc varicose vein cluster,10578796,CDM,0450,RC,37785,CPT,,,,,,outpatient,facility,,,7217.00,2165.10,774.0,6134.45,,4460.11,,,percent of total billed charges,,,,,,,,,3521.90,,,percent of total billed charges,,,3640.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5412.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5412.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6134.45,,,percent of total billed charges,,,3319.82,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Ligate  divide  and/or exc varicose vein cluster,10578796,CDM,0450,RC,37785,CPT,05183,APC,,,,outpatient,facility,,,7217.00,2165.10,1447.58,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,1447.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,1447.58,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,1447.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Ligate  divide  and/or exc varicose vein cluster,10578796,CDM,0450,RC,37785,CPT,103,EAPG,,,,outpatient,facility,,,7217.00,2165.10,3957.11,9892.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9892.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,8408.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3957.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4761.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,5237.76,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH SWAN-GANZ S TIP 7FX110CM,10578825,CDM,0272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,337.43,,,percent of total billed charges,,,,,,,,service not payable,266.45,,,percent of total billed charges,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,354.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET VIVACIT-E 36MM SZF,10578826,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET VIVACIT-E 36MM SZF,10578826,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ15 15X129MM,10578827,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ15 15X129MM,10578827,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB BEARING SZ2 14MM,10578828,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB BEARING SZ2 14MM,10578828,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURFACE 11MM RT,10578831,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURFACE 11MM RT,10578831,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ 11,10578832,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ 11,10578832,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA PKS 5DEG R SZH,10578833,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA PKS 5DEG R SZH,10578833,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL COMP 38X19X39MM,10578834,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6033.00,1809.90,2340.80,5128.05,,2956.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2533.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2340.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2564.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4524.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3016.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5128.05,,,percent of total billed charges,,,2714.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL COMP 38X19X39MM,10578834,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6033.00,1809.90,2533.86,5128.05,,2956.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2533.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3043.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2564.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4524.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3016.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4524.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5128.05,,,percent of total billed charges,,,2775.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 3.5X20MM,10578835,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,493.00,147.90,191.28,419.05,,,,,,,,,,,,,,,,,,,,191.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.05,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 3.5X20MM,10578835,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,,,,,,,,,,,,service not payable,,,,,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT TIBIAL REV SZ3-4 5MM,10578836,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT TIBIAL REV SZ3-4 5MM,10578836,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH SYN DYN MALL MD 1 1X7MM,10578837,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,8789.00,2636.70,3410.13,7470.65,,4306.61,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3691.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3410.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3735.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6591.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4394.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7470.65,,,percent of total billed charges,,,3955.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH SYN DYN MALL MD 1 1X7MM,10578837,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,8789.00,2636.70,3691.38,7470.65,,4306.61,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3691.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4433.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3735.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6591.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4394.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6591.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7470.65,,,percent of total billed charges,,,4042.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAR TI FT NS T7 2.7X20,10578838,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,686.00,205.80,266.17,583.10,,,,,,,,,,,,,,,,,,,,266.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,291.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,514.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,343.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.10,,,percent of total billed charges,,,308.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAR TI FT NS T7 2.7X20,10578838,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,686.00,205.80,291.55,583.10,,,,,,,,,,,,,service not payable,,,,,,,346.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,291.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,514.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,343.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,514.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,583.10,,,percent of total billed charges,,,315.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2X20MM,10578839,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,374.00,112.20,145.11,317.90,,,,,,,,,,,,,,,,,,,,145.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.90,,,percent of total billed charges,,,168.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2X20MM,10578839,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,374.00,112.20,158.95,317.90,,,,,,,,,,,,,service not payable,,,,,,,188.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,280.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,317.90,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SURGICAL CPR VIPER,10578840,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5192.00,1557.60,2014.50,4413.20,,2544.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2180.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2014.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2206.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4413.20,,,percent of total billed charges,,,2336.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SURGICAL CPR VIPER,10578840,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5192.00,1557.60,2180.64,4413.20,,2544.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2180.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2618.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2206.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4413.20,,,percent of total billed charges,,,2388.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 12.0,10578841,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 12.0,10578841,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 12.5,10578842,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 12.5,10578842,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL 26.5,10578843,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL 26.5,10578843,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75 SIZE 8.5,10578844,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75 SIZE 8.5,10578844,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75 SIZE 11.5,10578845,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75 SIZE 11.5,10578845,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 3.75 SIZE 17.0,10578846,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 3.75 SIZE 17.0,10578846,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SNGLPC NATURAL IOL 36.0,10578847,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SNGLPC NATURAL IOL 36.0,10578847,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD COMPONENT ENDO ll 54MM,10578848,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD COMPONENT ENDO ll 54MM,10578848,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LLRM 5.0X70MM,10578849,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LLRM 5.0X70MM,10578849,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM LLRM 10X70MM,10578850,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3754.00,1126.20,1456.55,3190.90,,,,,,,,,,,,,,,,,,,,1456.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1595.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2815.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1877.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3190.90,,,percent of total billed charges,,,1689.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM LLRM 10X70MM,10578850,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3754.00,1126.20,1595.45,3190.90,,,,,,,,,,,,,service not payable,,,,,,,1893.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1595.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2815.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1877.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2815.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3190.90,,,percent of total billed charges,,,1726.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CONSTRAINED LT 70MM,10578851,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21473.00,6441.90,8331.52,18252.05,,10521.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9018.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8331.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9126.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16104.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10736.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18252.05,,,percent of total billed charges,,,9662.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CONSTRAINED LT 70MM,10578851,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21473.00,6441.90,9018.66,18252.05,,10521.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9018.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10830.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9126.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16104.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10736.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16104.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18252.05,,,percent of total billed charges,,,9877.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACET ENDO II 47MM,10578852,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACET ENDO II 47MM,10578852,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT IMPLANT 20X20MM STR BRIDGE,10578855,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7852.00,2355.60,3046.58,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3046.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6674.20,,,percent of total billed charges,,,3533.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT IMPLANT 20X20MM STR BRIDGE,10578855,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7852.00,2355.60,3297.84,6674.20,,3847.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3960.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3337.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5889.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3926.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5889.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6674.20,,,percent of total billed charges,,,3611.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT IMPLANT 18X18MM STR BRIDGE,10578856,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7180.00,2154.00,2785.84,6103.0,,3518.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3015.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2785.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3051.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5385.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3590.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6103.0,,,percent of total billed charges,,,3231.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT IMPLANT 18X18MM STR BRIDGE,10578856,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7180.00,2154.00,3015.60,6103.0,,3518.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3015.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3621.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3051.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5385.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3590.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5385.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6103.0,,,percent of total billed charges,,,3302.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 1.6X220MM,10578857,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,439.40,,,percent of total billed charges,,,,,,,,service not payable,346.97,,,percent of total billed charges,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,462.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 2.8X220MM,10578858,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,564.00,169.20,239.70,479.40,,348.55,,,percent of total billed charges,,,,,,,,service not payable,275.23,,,percent of total billed charges,,,284.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.70,,,percent of total billed charges,,,,,,,,,423.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,282.0,,,percent of total billed charges,,,,,,,,service not payable,423.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,479.40,,,percent of total billed charges,,,259.44,,,percent of total billed charges,,,,,,,,,366.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,366.60,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.5X60MM HEADLESS,10578861,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2745.00,823.50,1065.06,2333.25,,,,,,,,,,,,,,,,,,,,1065.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2333.25,,,percent of total billed charges,,,1235.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.5X60MM HEADLESS,10578861,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2745.00,823.50,1166.62,2333.25,,,,,,,,,,,,,service not payable,,,,,,,1384.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2333.25,,,percent of total billed charges,,,1262.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 4.5X65MM HEADLESS,10578862,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2745.00,823.50,1065.06,2333.25,,,,,,,,,,,,,,,,,,,,1065.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2333.25,,,percent of total billed charges,,,1235.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 4.5X65MM HEADLESS,10578862,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2745.00,823.50,1166.62,2333.25,,,,,,,,,,,,,service not payable,,,,,,,1384.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2333.25,,,percent of total billed charges,,,1262.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5X80MM HEADLESS,10578863,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3469.00,1040.70,1345.97,2948.65,,,,,,,,,,,,,,,,,,,,1345.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1474.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2601.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1734.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2948.65,,,percent of total billed charges,,,1561.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5X80MM HEADLESS,10578863,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3469.00,1040.70,1474.32,2948.65,,,,,,,,,,,,,service not payable,,,,,,,1749.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1474.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2601.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1734.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2601.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2948.65,,,percent of total billed charges,,,1595.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 6.5X90MM HEADLESS,10578864,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3469.00,1040.70,1345.97,2948.65,,,,,,,,,,,,,,,,,,,,1345.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1474.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2601.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1734.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2948.65,,,percent of total billed charges,,,1561.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 6.5X90MM HEADLESS,10578864,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3469.00,1040.70,1474.32,2948.65,,,,,,,,,,,,,service not payable,,,,,,,1749.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1474.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2601.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1734.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2601.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2948.65,,,percent of total billed charges,,,1595.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Thyroglobulin Antibody,10579,CDM,0300,RC,86800,CPT,,,,,,outpatient,facility,,,34.00,10.20,14.73,35.96,,19.73,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,15.59,,,fee schedule,,,14.73,,,fee schedule,,,33.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,32.93,,,fee schedule,,,15.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",15.9,,,fee schedule,,,35.96,,,fee schedule,,,,,,,,,15.59,,,fee schedule,,,,,,,,,20.64,,,fee schedule,,,32.46,,,fee schedule,,,25.5,,,percent of total billed charges,,,15.59,,,fee schedule,,,15.11,,,fee schedule,,,15.9,,,fee schedule,,,24.27,,,fee schedule,,,15.59,,,fee schedule,,,25.5,,,percent of total billed charges,,,,,,,,,15.9,,,fee schedule,,,,,,,,,28.90,,,percent of total billed charges,,,15.64,,,percent of total billed charges,,,,,,,,,17.5,,,fee schedule,,,15.59,,,fee schedule,,,,,,,,,15.43,,,fee schedule,,,15.59,,,fee schedule,,,,,,,,,15.75,,,fee schedule,,,,,,,,
Thyroglobulin Antibody,10579,CDM,0300,RC,86800,CPT,394,EAPG,,,,outpatient,facility,,,34.00,10.20,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LEAD NEURO SPNL PRECISION 70CM,10580461,CDM,0278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD NEURO SPNL PRECISION 70CM,10580461,CDM,0278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SONICANCHOR 2.5X10MM C-7,10580467,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2343.00,702.90,909.08,1991.55,,,,,,,,,,,,,,,,,,,,909.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,995.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1757.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1171.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1991.55,,,percent of total billed charges,,,1054.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SONICANCHOR 2.5X10MM C-7,10580467,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2343.00,702.90,995.77,1991.55,,,,,,,,,,,,,service not payable,,,,,,,1181.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,995.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1757.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1171.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1757.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1991.55,,,percent of total billed charges,,,1077.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Esophageal balloon distension study (FLIP),10580770,CDM,0750,RC,91040,CPT,,,,,,outpatient,facility,,,1519.00,455.70,698.74,5463.36,,1519.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,766.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,1139.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,1139.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1291.15,,,percent of total billed charges,,,698.74,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Esophageal balloon distension study (FLIP),10580770,CDM,0750,RC,91040,CPT,05723,APC,,,,outpatient,facility,,,1519.00,455.70,488.06,1168.65,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1070.40,,,fee schedule,,,488.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",519.01,,,fee schedule,,,1168.65,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,1054.88,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,488.06,,,fee schedule,,,519.01,,,fee schedule,,,,,,,,,508.83,,,fee schedule,,,,,,,,,488.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",519.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,,,,,,,508.83,,,fee schedule,,,,,,,,,513.89,,,fee schedule,,,,,,,,
END-Esophageal balloon distension study (FLIP),10580770,CDM,0750,RC,91040,CPT,130,EAPG,,,,outpatient,facility,,,1519.00,455.70,565.93,2256.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2256.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1917.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,565.93,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1178.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1296.48,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97761 Prosthetic Training,10580791,CDM,0420,RC,97761,CPT,,,,,GP  ,outpatient,facility,,,148.00,44.40,24.37,260.0,,91.46,,,percent of total billed charges,,,37.57,,,fee schedule,,,72.22,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,79.03,,,fee schedule,,,24.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",38.36,,,fee schedule,,,86.38,,,fee schedule,,,,,,,,,37.61,,,fee schedule,,,,,,,,,173.0,,,per diem,,,77.89,,,fee schedule,,,111.0,,,percent of total billed charges,,,37.57,,,fee schedule,,,24.37,,,fee schedule,,,38.32,,,fee schedule,,,204.0,,,per diem,,,37.61,,,fee schedule,,,111.0,,,percent of total billed charges,,,24.37,,,fee schedule,,,38.32,,,fee schedule,,,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,37.61,,,fee schedule,,,,,,,,,229.0,,,per diem,,,37.57,,,fee schedule,,,,,,,,,37.57,,,fee schedule,,,,,,,,
PT 97761 Prosthetic Training,10580791,CDM,0420,RC,97761,CPT,269,EAPG,,,GP  ,outpatient,facility,,,148.00,44.40,62.90,340.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,289.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,62.90,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,148.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,163.0,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 29520 Strapping Hip,10580795,CDM,0420,RC,29520,CPT,,,,,GP  ,outpatient,facility,,,196.00,58.80,90.16,260.0,,121.13,,,percent of total billed charges,,,,,,,,,95.65,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.60,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PT 29520 Strapping Hip,10580795,CDM,0420,RC,29520,CPT,05734,APC,,,GP  ,outpatient,facility,,,196.00,58.80,118.57,283.90,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,260.03,,,fee schedule,,,118.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",126.08,,,fee schedule,,,283.90,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,256.26,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,118.57,,,fee schedule,,,126.08,,,fee schedule,,,,,,,,,123.61,,,fee schedule,,,,,,,,,118.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",126.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,,,,,,,123.61,,,fee schedule,,,,,,,,,124.84,,,fee schedule,,,,,,,,
PT 29520 Strapping Hip,10580795,CDM,0420,RC,29520,CPT,40,EAPG,,,GP  ,outpatient,facility,,,196.00,58.80,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 29799 Strapping Low Back,10580799,CDM,0420,RC,29799,CPT,,,,,GP  ,outpatient,facility,,,204.00,61.20,93.84,260.0,,126.07,,,percent of total billed charges,,,,,,,,,99.55,,,percent of total billed charges,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.0,,,per diem,,,,,,,,,153.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.0,,,per diem,,,,,,,,,153.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.40,,,percent of total billed charges,,,93.84,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,,,,,,,,,,,,,229.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PT 29799 Strapping Low Back,10580799,CDM,0420,RC,29799,CPT,05101,APC,,,GP  ,outpatient,facility,,,204.00,61.20,145.14,347.54,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,318.32,,,fee schedule,,,145.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",154.35,,,fee schedule,,,347.54,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,313.71,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,145.14,,,fee schedule,,,154.35,,,fee schedule,,,,,,,,,151.32,,,fee schedule,,,,,,,,,145.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",154.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,,,,,,,151.32,,,fee schedule,,,,,,,,,152.83,,,fee schedule,,,,,,,,
PT 29799 Strapping Low Back,10580799,CDM,0420,RC,29799,CPT,40,EAPG,,,GP  ,outpatient,facility,,,204.00,61.20,93.0,611.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,519.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,110.15,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,93.0,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,102.3,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PT 97026 Infrared Application,10580804,CDM,0420,RC,97026,CPT,,,,,GP  ,outpatient,facility,,,38.00,11.40,3.99,260.0,,17.33,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA PT/OT/ST PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100.00%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.12,,,fee schedule,,,12.93,,,fee schedule,,,226.98,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Days in Service Type} * 234.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,12.88,,,fee schedule,,,3.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.21,,,fee schedule,,,13.99,,,fee schedule,,,,,,,,,6.09,,,fee schedule,,,,,,,,,173.0,,,per diem,,,12.69,,,fee schedule,,,28.5,,,percent of total billed charges,,,6.12,,,fee schedule,,,3.99,,,fee schedule,,,6.24,,,fee schedule,,,204.0,,,per diem,,,6.09,,,fee schedule,,,28.5,,,percent of total billed charges,,,3.99,,,fee schedule,,,6.24,,,fee schedule,,,,,,,,,32.30,,,percent of total billed charges,,,17.48,,,percent of total billed charges,,,,,,,,,260.0,,,per diem,,,6.09,,,fee schedule,,,,,,,,,229.0,,,per diem,,,6.12,,,fee schedule,,,,,,,,,6.12,,,fee schedule,,,,,,,,
PT 97026 Infrared Application,10580804,CDM,0420,RC,97026,CPT,493,EAPG,,,GP  ,outpatient,facility,,,38.00,11.40,38.0,166.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,141.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,72.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,79.79,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW SM HEX RECESS 2.7X26MM,10580981,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X26MM,10580981,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AFO SPIRAL PREFAB,10580984,CDM,0274,RC,L1951,HCPCS,,,,,,inpatient,facility,,,3659.00,1097.70,1419.69,3110.15,,,,,,,,,,,,,,,,,,,,1419.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1555.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2744.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1829.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3110.15,,,percent of total billed charges,,,1646.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AFO SPIRAL PREFAB,10580984,CDM,0274,RC,L1951,HCPCS,,,,,,outpatient,facility,,,3659.00,1097.70,990.79,3110.15,,,,,,,,990.79,,,fee schedule,,,,,,,,,1845.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,2084.28,,,fee schedule,,,,,,,,service not payable,1010.61,,,fee schedule,,,2275.59,,,fee schedule,,,,,,,,,990.79,,,fee schedule,,,,,,,,,1555.08,,,percent of total billed charges,,Paid in addition to outpatient services ,2054.08,,,fee schedule,,,2744.25,,,percent of total billed charges,,,990.79,,,fee schedule,,,,,,,,service not payable,1010.61,,,fee schedule,,,1829.5,,,percent of total billed charges,,Paid in addition to outpatient services ,990.79,,,fee schedule,,,2744.25,,,percent of total billed charges,,,,,,,,service not payable,1010.61,,,fee schedule,,,,,,,,,3110.15,,,percent of total billed charges,,,1683.14,,,percent of total billed charges,,,,,,,,,,,,,,,990.79,,,fee schedule,,,,,,,,,,,,,,,990.79,,,fee schedule,,,,,,,,,1000.7,,,fee schedule,,,,,,,,
STEM TIB SPLINED V2 16X80MM,10580985,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIB SPLINED V2 16X80MM,10580985,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FXD BG CV SZ 3 20MM,10580988,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FXD BG CV SZ 3 20MM,10580988,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BIO DBM WITH CHIPS,10580989,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4187.00,1256.10,1624.56,3558.95,,,,,,,,,,,,,,,,,,,,1624.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1779.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3140.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2093.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3558.95,,,percent of total billed charges,,,1884.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BIO DBM WITH CHIPS,10580989,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4187.00,1256.10,1779.47,3558.95,,,,,,,,,,,,,service not payable,,,,,,,2111.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1779.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3140.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2093.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3140.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3558.95,,,percent of total billed charges,,,1926.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAX4.0X18MM OASYS,10580990,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAX4.0X18MM OASYS,10580990,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAX4.0X14MM OASYS,10580991,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2303.00,690.90,893.56,1957.55,,,,,,,,,,,,,,,,,,,,893.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1957.55,,,percent of total billed charges,,,1036.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAX4.0X14MM OASYS,10580991,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2303.00,690.90,978.77,1957.55,,,,,,,,,,,,,service not payable,,,,,,,1161.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,978.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1727.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1151.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1727.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1957.55,,,percent of total billed charges,,,1059.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRT APTUS TI 8X2.5MM,10580992,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,592.00,177.60,229.70,503.20,,,,,,,,,,,,,,,,,,,,229.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,444.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,296.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.20,,,percent of total billed charges,,,266.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRT APTUS TI 8X2.5MM,10580992,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,592.00,177.60,251.60,503.20,,,,,,,,,,,,,service not payable,,,,,,,298.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,251.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,444.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,296.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,444.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,503.20,,,percent of total billed charges,,,272.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BLUE LCKG 2.5X8MM,10580993,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,967.00,290.10,375.20,821.95,,,,,,,,,,,,,,,,,,,,375.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,725.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,483.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,821.95,,,percent of total billed charges,,,435.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BLUE LCKG 2.5X8MM,10580993,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,967.00,290.10,410.97,821.95,,,,,,,,,,,,,service not payable,,,,,,,487.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,410.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,725.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,483.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,725.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,821.95,,,percent of total billed charges,,,444.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 5.0X6MM,10580994,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 5.0X6MM,10580994,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 5.5X6MM,10580995,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 5.5X6MM,10580995,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 6.0X6MM,10580996,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 6.0X6MM,10580996,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 6.5X6MM,10580997,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 6.5X6MM,10580997,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 7.0X6MM,10580998,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 7.0X6MM,10580998,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 7.5X6MM,10580999,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 7.5X6MM,10580999,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 8.0X6MM,10581000,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 8.0X6MM,10581000,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL BEARING SZ5 14MM,10581001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL BEARING SZ5 14MM,10581001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 8.5X6MM,10581002,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 8.5X6MM,10581002,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 9.0X6MM,10581004,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 9.0X6MM,10581004,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 9.5X6MM,10581005,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 9.5X6MM,10581005,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFNA 14X400MM LT,10581006,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10701.00,3210.30,4151.99,9095.85,,5243.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4151.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4547.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8025.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5350.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9095.85,,,percent of total billed charges,,,4815.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFNA 14X400MM LT,10581006,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10701.00,3210.30,4494.42,9095.85,,5243.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5397.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4547.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8025.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5350.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8025.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9095.85,,,percent of total billed charges,,,4922.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 10.0X6MM,10581007,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 10.0X6MM,10581007,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 10.5X6MM,10581008,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 10.5X6MM,10581008,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 11.0X6MM,10581009,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 11.0X6MM,10581009,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB LCKG RT 10H,10581010,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3301.00,990.30,1280.79,2805.85,,,,,,,,,,,,,,,,,,,,1280.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1402.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2475.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2805.85,,,percent of total billed charges,,,1485.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB LCKG RT 10H,10581010,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3301.00,990.30,1402.92,2805.85,,,,,,,,,,,,,service not payable,,,,,,,1665.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1402.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2475.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2475.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2805.85,,,percent of total billed charges,,,1518.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 11.5X6MM,10581011,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 11.5X6MM,10581011,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 12.0X6MM,10581012,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 12.0X6MM,10581012,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 12.5X6MM,10581013,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 12.5X6MM,10581013,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 3.5X10MM,10581014,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 3.5X10MM,10581014,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 13.0X6MM,10581015,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 13.0X6MM,10581015,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4.0X70MM,10581016,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4.0X70MM,10581016,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 13.5X6MM,10581017,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 13.5X6MM,10581017,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4.0X65MM,10581018,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4.0X65MM,10581018,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 14.0X6MM,10581019,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 14.0X6MM,10581019,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 14.5X6MM,10581020,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 14.5X6MM,10581020,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 15.0X6MM,10581021,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 15.0X6MM,10581021,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 15.5X6MM,10581022,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 15.5X6MM,10581022,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 16.0X6MM,10581023,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 16.0X6MM,10581023,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 16.5X6MM,10581024,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 16.5X6MM,10581024,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 17.0X6MM,10581025,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 17.0X6MM,10581025,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 17.5X6MM,10581026,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 17.5X6MM,10581026,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 18.0X6MM,10581027,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 18.0X6MM,10581027,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 18.5X6MM,10581028,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 18.5X6MM,10581028,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 19.0X6MM,10581029,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 19.0X6MM,10581029,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 19.5X6MM,10581030,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 19.5X6MM,10581030,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 20.0X6MM,10581031,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 20.0X6MM,10581031,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 20.5X6MM,10581032,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 20.5X6MM,10581032,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 21.0X6MM,10581033,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 21.0X6MM,10581033,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 21.5X6MM,10581034,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 21.5X6MM,10581034,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 22.0X6MM,10581035,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 22.0X6MM,10581035,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 22.5X6MM,10581036,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 22.5X6MM,10581036,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 23.0X6MM,10581037,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 23.0X6MM,10581037,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 23.5X6MM,10581038,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 23.5X6MM,10581038,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 24.0X6MM,10581039,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 24.0X6MM,10581039,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 24.5X6MM,10581040,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 24.5X6MM,10581040,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 25.0X6MM,10581041,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 25.0X6MM,10581041,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 25.5X6MM,10581042,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 25.5X6MM,10581042,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 26.0X6MM,10581043,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 26.0X6MM,10581043,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 26.5X6MM,10581044,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 26.5X6MM,10581044,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 27.0X6MM,10581045,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 27.0X6MM,10581045,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 27.5X6MM,10581046,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 27.5X6MM,10581046,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 28.0X6MM,10581047,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 28.0X6MM,10581047,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 28.5X6MM,10581048,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 28.5X6MM,10581048,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 29.0X6MM,10581049,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 29.0X6MM,10581049,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 29.5X6MM,10581050,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 29.5X6MM,10581050,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 30.0X6MM,10581051,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 30.0X6MM,10581051,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 30.5X6MM,10581052,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 30.5X6MM,10581052,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 31.0X6MM,10581053,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 31.0X6MM,10581053,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 31.5X6MM,10581054,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 31.5X6MM,10581054,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 32.5X6MM,10581056,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 32.5X6MM,10581056,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 33.0X6MM,10581057,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 33.0X6MM,10581057,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 33.5X6MM,10581058,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 33.5X6MM,10581058,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR 34.0X6MM,10581059,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,875.00,262.50,339.5,743.75,,,,,,,,,,,,,,,,,,,,339.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.75,,,percent of total billed charges,,,393.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR 34.0X6MM,10581059,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,875.00,262.50,371.88,743.75,,,,,,,,,,,,,service not payable,,,,,,,441.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,371.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,656.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,437.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,656.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,743.75,,,percent of total billed charges,,,402.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX NON-LCKG 2.4X10MM,10581061,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX NON-LCKG 2.4X10MM,10581061,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 4H WRST SPNNG,10581062,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5885.00,1765.50,2283.38,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2283.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5002.25,,,percent of total billed charges,,,2648.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 4H WRST SPNNG,10581062,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5885.00,1765.50,2471.70,5002.25,,2883.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2471.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2968.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2501.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4413.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2942.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4413.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5002.25,,,percent of total billed charges,,,2707.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB TRIATHLON CR X3,10581064,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB TRIATHLON CR X3,10581064,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 5X68MM,10581065,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1388.00,416.40,538.54,1179.8,,,,,,,,,,,,,,,,,,,,538.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,589.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1041.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,694.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1179.8,,,percent of total billed charges,,,624.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 5X68MM,10581065,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1388.00,416.40,589.90,1179.8,,,,,,,,,,,,,service not payable,,,,,,,700.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,589.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1041.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,694.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1041.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1179.8,,,percent of total billed charges,,,638.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RECON 6.5X90MM,10581066,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1842.00,552.60,714.70,1565.7,,,,,,,,,,,,,,,,,,,,714.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1565.7,,,percent of total billed charges,,,828.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RECON 6.5X90MM,10581066,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1842.00,552.60,782.85,1565.7,,,,,,,,,,,,,service not payable,,,,,,,929.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1565.7,,,percent of total billed charges,,,847.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RECON 6.5X85MM,10581067,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1842.00,552.60,714.70,1565.7,,,,,,,,,,,,,,,,,,,,714.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1565.7,,,percent of total billed charges,,,828.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RECON 6.5X85MM,10581067,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1842.00,552.60,782.85,1565.7,,,,,,,,,,,,,service not payable,,,,,,,929.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,782.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1381.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,921.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1381.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1565.7,,,percent of total billed charges,,,847.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 14MM LT 400MM,10581068,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10291.00,3087.30,3992.91,8747.35,,5042.59,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4322.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3992.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4373.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7718.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5145.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8747.35,,,percent of total billed charges,,,4630.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 14MM LT 400MM,10581068,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10291.00,3087.30,4322.22,8747.35,,5042.59,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4322.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5190.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4373.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7718.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5145.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7718.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8747.35,,,percent of total billed charges,,,4733.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Colporrhaphy suture injury of vagina,10581426,CDM,0450,RC,57200,CPT,,,,,,outpatient,facility,,,6506.00,1951.80,774.0,5530.10,,4020.71,,,percent of total billed charges,,,,,,,,,3174.93,,,percent of total billed charges,,,3281.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4879.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4879.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5530.10,,,percent of total billed charges,,,2992.76,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Colporrhaphy suture injury of vagina,10581426,CDM,0450,RC,57200,CPT,05414,APC,,,,outpatient,facility,,,6506.00,1951.80,1462.31,7002.93,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6414.18,,,fee schedule,,,1462.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3110.04,,,fee schedule,,,7002.93,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,6321.23,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,1462.31,,,fee schedule,,,3110.04,,,fee schedule,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,1462.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3110.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,,,,,,,3049.06,,,fee schedule,,,,,,,,,3079.43,,,fee schedule,,,,,,,,
Colporrhaphy suture injury of vagina,10581426,CDM,0450,RC,57200,CPT,188,EAPG,,,,outpatient,facility,,,6506.00,1951.80,3142.16,6582.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6582.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5594.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3544.06,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3142.16,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3456.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT PAPYRUS COVRED 3.0X15 PK,10582446,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PAPYRUS COVRED 3.0X15 PK,10582446,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT PAPYRUS COVRED 2.5X15 PK,10582447,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT PAPYRUS COVRED 2.5X15 PK,10582447,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE10-12 GH 16MM,10582449,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE10-12 GH 16MM,10582449,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD RT SZ 11,10582450,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD RT SZ 11,10582450,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ G RT,10582451,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ G RT,10582451,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF GH 10-12 RT 12MM,10582452,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF GH 10-12 RT 12MM,10582452,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL 13MMX38CM 125D R,10582454,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4461.00,1338.30,1730.87,3791.85,,,,,,,,,,,,,,,,,,,,1730.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1895.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3345.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2230.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3791.85,,,percent of total billed charges,,,2007.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL 13MMX38CM 125D R,10582454,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4461.00,1338.30,1895.92,3791.85,,,,,,,,,,,,,service not payable,,,,,,,2250.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1895.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3345.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2230.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3345.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3791.85,,,percent of total billed charges,,,2052.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT HEAD HIP 52MM,10582455,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT HEAD HIP 52MM,10582455,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 13X146MM,10582456,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 13X146MM,10582456,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC RT 3-5 AB 11MM,10582457,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC RT 3-5 AB 11MM,10582457,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ B RIGHT,10582458,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ B RIGHT,10582458,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR RIGHT SZ3,10582459,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR RIGHT SZ3,10582459,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR RIGHT SZ6,10582460,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR RIGHT SZ6,10582460,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART FEM RT 6-9 CD 10MM,10582461,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART FEM RT 6-9 CD 10MM,10582461,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB BCS RT SZ 3-4 12MM,10582462,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2357.00,707.10,914.52,2003.45,,,,,,,,,,,,,,,,,,,,914.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2003.45,,,percent of total billed charges,,,1060.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB BCS RT SZ 3-4 12MM,10582462,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2357.00,707.10,1001.72,2003.45,,,,,,,,,,,,,service not payable,,,,,,,1188.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1001.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1767.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1178.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1767.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2003.45,,,percent of total billed charges,,,1084.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS UV TORIC ASPHERIC 12.0D,10582463,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS UV TORIC ASPHERIC 12.0D,10582463,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SUPERCONDYLAR 12X200MM,10582464,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8985.00,2695.50,3486.18,7637.25,,4402.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3773.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3486.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3818.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6738.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4492.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7637.25,,,percent of total billed charges,,,4043.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SUPERCONDYLAR 12X200MM,10582464,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8985.00,2695.50,3773.70,7637.25,,4402.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3773.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4532.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3818.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6738.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4492.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6738.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7637.25,,,percent of total billed charges,,,4133.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL BASE RP ATTUNE SZ8,10582465,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL BASE RP ATTUNE SZ8,10582465,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPR FT SCREW 3.5 MINI 48MM,10582466,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPR FT SCREW 3.5 MINI 48MM,10582466,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFNA RIGHT 12MM X 380MM,10582468,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFNA RIGHT 12MM X 380MM,10582468,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TFN FEM GOLD 115MM,10582469,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3311.00,993.30,1284.67,2814.35,,,,,,,,,,,,,,,,,,,,1284.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2814.35,,,percent of total billed charges,,,1489.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TFN FEM GOLD 115MM,10582469,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3311.00,993.30,1407.18,2814.35,,,,,,,,,,,,,service not payable,,,,,,,1670.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1407.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2483.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1655.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2483.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2814.35,,,percent of total billed charges,,,1523.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LEAD ATTAIN PERFORMA 4798 88CM,10582731,CDM,0278,RC,C1900,HCPCS,,,,,,inpatient,facility,,,7344.00,2203.20,2849.47,6242.40,,3598.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3084.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2849.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3121.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5508.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3672.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6242.40,,,percent of total billed charges,,,3304.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEAD ATTAIN PERFORMA 4798 88CM,10582731,CDM,0278,RC,C1900,HCPCS,,,,,,outpatient,facility,,,7344.00,2203.20,3084.48,6242.40,,3598.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3084.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3704.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3121.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5508.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3672.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5508.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6242.40,,,percent of total billed charges,,,3378.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Infant Heated High flow Subsequent Daily - RT Only,10583164,CDM,0460,RC,94640,CPT,,,,,,outpatient,facility,,,340.00,102.00,144.5,983.0,,210.12,,,percent of total billed charges,,,,,,,,,165.92,,,percent of total billed charges,,,171.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,,,,,,,,255.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,170.0,,,percent of total billed charges,,,,,,,,,255.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,289.0,,,percent of total billed charges,,,156.40,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Infant Heated High flow Subsequent Daily - RT Only,10583164,CDM,0460,RC,94640,CPT,05791,APC,,,,outpatient,facility,,,340.00,102.00,187.09,447.98,,,,,,,,195.05,,,fee schedule,,,,,,,,,,,,,,,410.32,,,fee schedule,,,187.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",198.95,,,fee schedule,,,447.98,,,fee schedule,,,,,,,,,195.05,,,fee schedule,,,,,,,,,,,,,,,404.37,,,fee schedule,,,,,,,,,195.05,,,fee schedule,,,187.09,,,fee schedule,,,198.95,,,fee schedule,,,,,,,,,195.05,,,fee schedule,,,,,,,,,187.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",198.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.05,,,fee schedule,,,,,,,,,,,,,,,195.05,,,fee schedule,,,,,,,,,196.99,,,fee schedule,,,,,,,,
Infant Heated High flow Subsequent Daily - RT Only,10583164,CDM,0460,RC,94640,CPT,412,EAPG,,,,outpatient,facility,,,340.00,102.00,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Infant Oxygen Daily Supply - RT Only Oxygen Therap,10583165,CDM,0410,RC,94799,CPT,,,,,,outpatient,facility,,,585.00,175.50,205.0,497.25,,361.53,,,percent of total billed charges,,,,,,,,,285.48,,,percent of total billed charges,,,295.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.63,,,percent of total billed charges,,,,,,,,,438.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,,438.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,497.25,,,percent of total billed charges,,,269.10,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Infant Oxygen Daily Supply - RT Only Oxygen Therap,10583165,CDM,0410,RC,94799,CPT,05721,APC,,,,outpatient,facility,,,585.00,175.50,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Infant Oxygen Daily Supply - RT Only Oxygen Therap,10583165,CDM,0410,RC,94799,CPT,412,EAPG,,,,outpatient,facility,,,585.00,175.50,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Infant Oxygen Set-Up - RT Only Oxygen Therapy Proc,10583166,CDM,0410,RC,94799,CPT,,,,,,outpatient,facility,,,521.00,156.30,205.0,442.85,,321.98,,,percent of total billed charges,,,,,,,,,254.25,,,percent of total billed charges,,,262.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.43,,,percent of total billed charges,,,,,,,,,390.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.5,,,percent of total billed charges,,,,,,,,,390.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,442.85,,,percent of total billed charges,,,239.66,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Infant Oxygen Set-Up - RT Only Oxygen Therapy Proc,10583166,CDM,0410,RC,94799,CPT,05721,APC,,,,outpatient,facility,,,521.00,156.30,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Infant Oxygen Set-Up - RT Only Oxygen Therapy Proc,10583166,CDM,0410,RC,94799,CPT,412,EAPG,,,,outpatient,facility,,,521.00,156.30,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Infant Oxyhood Set Up - RT Only Oxygen Therapy Pro,10583167,CDM,0410,RC,94799,CPT,,,,,,outpatient,facility,,,889.00,266.70,205.0,755.65,,549.40,,,percent of total billed charges,,,,,,,,,433.83,,,percent of total billed charges,,,448.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.82,,,percent of total billed charges,,,,,,,,,666.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,444.5,,,percent of total billed charges,,,,,,,,,666.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,755.65,,,percent of total billed charges,,,408.94,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Infant Oxyhood Set Up - RT Only Oxygen Therapy Pro,10583167,CDM,0410,RC,94799,CPT,05721,APC,,,,outpatient,facility,,,889.00,266.70,143.91,344.60,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,315.63,,,fee schedule,,,143.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",153.04,,,fee schedule,,,344.60,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,311.06,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,143.91,,,fee schedule,,,153.04,,,fee schedule,,,,,,,,,150.04,,,fee schedule,,,,,,,,,143.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",153.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,,,,,,,150.04,,,fee schedule,,,,,,,,,151.53,,,fee schedule,,,,,,,,
Infant Oxyhood Set Up - RT Only Oxygen Therapy Pro,10583167,CDM,0410,RC,94799,CPT,412,EAPG,,,,outpatient,facility,,,889.00,266.70,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Infant Vent Initiate/Start (Set-Up) - Mechanical V,10583185,CDM,0410,RC,94002,CPT,,,,,,outpatient,facility,,,1613.00,483.90,205.0,1371.05,,996.83,,,percent of total billed charges,,,,,,,,,787.14,,,percent of total billed charges,,,813.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.52,,,percent of total billed charges,,,,,,,,,1209.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.5,,,percent of total billed charges,,,,,,,,,1209.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1371.05,,,percent of total billed charges,,,741.98,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Infant Vent Initiate/Start (Set-Up) - Mechanical V,10583185,CDM,0410,RC,94002,CPT,05801,APC,,,,outpatient,facility,,,1613.00,483.90,608.10,1456.07,,,,,,,,633.97,,,fee schedule,,,,,,,,,,,,,,,1333.66,,,fee schedule,,,608.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",646.65,,,fee schedule,,,1456.07,,,fee schedule,,,,,,,,,633.97,,,fee schedule,,,,,,,,,,,,,,,1314.33,,,fee schedule,,,,,,,,,633.97,,,fee schedule,,,608.10,,,fee schedule,,,646.65,,,fee schedule,,,,,,,,,633.97,,,fee schedule,,,,,,,,,608.10,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",646.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,633.97,,,fee schedule,,,,,,,,,,,,,,,633.97,,,fee schedule,,,,,,,,,640.28,,,fee schedule,,,,,,,,
Infant Vent Initiate/Start (Set-Up) - Mechanical V,10583185,CDM,0410,RC,94002,CPT,67,EAPG,,,,outpatient,facility,,,1613.00,483.90,1538.39,4242.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4242.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3606.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1538.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1538.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1538.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2693.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2962.61,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Infant Vent Maintain (Subsequent Daily) - Mechanic,10583186,CDM,0410,RC,94003,CPT,,,,,,outpatient,facility,,,1015.00,304.50,205.0,862.75,,627.27,,,percent of total billed charges,,,,,,,,,495.32,,,percent of total billed charges,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Infant Vent Maintain (Subsequent Daily) - Mechanic,10583186,CDM,0410,RC,94003,CPT,05801,APC,,,,outpatient,facility,,,1015.00,304.50,608.10,1456.07,,,,,,,,633.97,,,fee schedule,,,,,,,,,,,,,,,1333.66,,,fee schedule,,,608.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",646.65,,,fee schedule,,,1456.07,,,fee schedule,,,,,,,,,633.97,,,fee schedule,,,,,,,,,,,,,,,1314.33,,,fee schedule,,,,,,,,,633.97,,,fee schedule,,,608.10,,,fee schedule,,,646.65,,,fee schedule,,,,,,,,,633.97,,,fee schedule,,,,,,,,,608.10,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",646.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,633.97,,,fee schedule,,,,,,,,,,,,,,,633.97,,,fee schedule,,,,,,,,,640.28,,,fee schedule,,,,,,,,
Infant Vent Maintain (Subsequent Daily) - Mechanic,10583186,CDM,0410,RC,94003,CPT,67,EAPG,,,,outpatient,facility,,,1015.00,304.50,1015.0,4242.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4242.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3606.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1015.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1015.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1015.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2693.28,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2962.61,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PIN SCHANZ ST 0.196X7IN,10584632,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1390.00,417.00,539.32,1181.5,,,,,,,,,,,,,,,,,,,,539.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1042.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,695.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1181.5,,,percent of total billed charges,,,625.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN SCHANZ ST 0.196X7IN,10584632,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1390.00,417.00,590.75,1181.5,,,,,,,,,,,,,service not payable,,,,,,,701.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,590.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1042.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,695.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1042.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1181.5,,,percent of total billed charges,,,639.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN SCHANZ ST 0.236X7IN,10584633,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1390.00,417.00,539.32,1181.5,,,,,,,,,,,,,,,,,,,,539.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1042.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,695.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1181.5,,,percent of total billed charges,,,625.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN SCHANZ ST 0.236X7IN,10584633,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1390.00,417.00,590.75,1181.5,,,,,,,,,,,,,service not payable,,,,,,,701.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,590.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1042.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,695.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1042.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1181.5,,,percent of total billed charges,,,639.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE COMP THD 2.8X25X200MM,10584634,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,869.00,260.70,337.17,738.65,,,,,,,,,,,,,,,,,,,,337.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,651.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.65,,,percent of total billed charges,,,391.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE COMP THD 2.8X25X200MM,10584634,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,869.00,260.70,369.32,738.65,,,,,,,,,,,,,service not payable,,,,,,,438.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,369.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,651.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,651.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,738.65,,,percent of total billed charges,,,399.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCP 2.7-3.5X142MM 6H,10584635,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7024.00,2107.20,2725.31,5970.40,,3441.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2725.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2985.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5268.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3512.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5970.40,,,percent of total billed charges,,,3160.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCP 2.7-3.5X142MM 6H,10584635,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7024.00,2107.20,2950.08,5970.40,,3441.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3542.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2985.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5268.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3512.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5268.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5970.40,,,percent of total billed charges,,,3231.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MP ST T8STRDRV 2.7X36MM,10584636,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,362.00,108.60,140.46,307.70,,,,,,,,,,,,,,,,,,,,140.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.70,,,percent of total billed charges,,,162.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MP ST T8STRDRV 2.7X36MM,10584636,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,362.00,108.60,153.85,307.70,,,,,,,,,,,,,service not payable,,,,,,,182.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,271.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,307.70,,,percent of total billed charges,,,166.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB REV G7 SZ E 52MM,10584637,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,14430.00,4329.00,5598.84,12265.5,,7070.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6060.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5598.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6132.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10822.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7215.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12265.5,,,percent of total billed charges,,,6493.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB REV G7 SZ E 52MM,10584637,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,14430.00,4329.00,6060.60,12265.5,,7070.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6060.60,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7278.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6132.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10822.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7215.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10822.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12265.5,,,percent of total billed charges,,,6637.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM CERAMIC 28MM 8.5,10584638,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7999.00,2399.70,3103.61,6799.15,,3919.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3359.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3103.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3399.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5999.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3999.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6799.15,,,percent of total billed charges,,,3599.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM CERAMIC 28MM 8.5,10584638,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7999.00,2399.70,3359.58,6799.15,,3919.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3359.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4034.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3399.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5999.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3999.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5999.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6799.15,,,percent of total billed charges,,,3679.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR HIP 58MM,10584639,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,28477.00,8543.10,11049.08,24205.45,,13953.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11960.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11049.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12102.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21357.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14238.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24205.45,,,percent of total billed charges,,,12814.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR HIP 58MM,10584639,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,28477.00,8543.10,11960.34,24205.45,,13953.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11960.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14363.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12102.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,21357.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14238.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21357.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,24205.45,,,percent of total billed charges,,,13099.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 52MM,10584640,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,31570.00,9471.00,12249.16,26834.5,,15469.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13259.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12249.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13417.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23677.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15785.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26834.5,,,percent of total billed charges,,,14206.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 52MM,10584640,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,31570.00,9471.00,13259.4,26834.5,,15469.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13259.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15923.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13417.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23677.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15785.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23677.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26834.5,,,percent of total billed charges,,,14522.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT DUAL K2 PROCESSOR,10584643,CDM,0274,RC,L8614,HCPCS,,,,,,inpatient,facility,,,30378.00,9113.40,11786.66,25821.30,,14885.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12758.76,,,percent of total billed charges,,Paid in addition to inpatient services ,11786.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12910.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22783.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15189.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25821.30,,,percent of total billed charges,,,13670.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT DUAL K2 PROCESSOR,10584643,CDM,0274,RC,L8614,HCPCS,,,,,,outpatient,facility,,,30378.00,9113.40,12758.76,25821.30,,14885.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12758.76,,,percent of total billed charges,,Paid in addition to outpatient services ,15322.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12910.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22783.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,15189.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22783.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,25821.30,,,percent of total billed charges,,,13973.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LK 3H PROX RT 77MM,10584644,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3149.00,944.70,1221.81,2676.65,,,,,,,,,,,,,,,,,,,,1221.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1338.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2361.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1574.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2676.65,,,percent of total billed charges,,,1417.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LK 3H PROX RT 77MM,10584644,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3149.00,944.70,1338.32,2676.65,,,,,,,,,,,,,service not payable,,,,,,,1588.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1338.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2361.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1574.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2361.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2676.65,,,percent of total billed charges,,,1448.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF DIOPTER 24.5,10584645,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF DIOPTER 24.5,10584645,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF DIOPTER 24.0,10584646,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF DIOPTER 24.0,10584646,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF DIOPTER 23.5,10584647,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF DIOPTER 23.5,10584647,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF DIOPTER 23.0,10584648,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF DIOPTER 23.0,10584648,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT TENDON FLEX GRACILIS,10584650,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3615.00,1084.50,1402.62,3072.75,,,,,,,,,,,,,,,,,,,,1402.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1536.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2711.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1807.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3072.75,,,percent of total billed charges,,,1626.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TENDON FLEX GRACILIS,10584650,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3615.00,1084.50,1536.38,3072.75,,,,,,,,,,,,,service not payable,,,,,,,1823.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1536.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2711.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1807.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2711.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3072.75,,,percent of total billed charges,,,1662.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STOCKING KNEE HIGH SZ 3 BLACK,10584998,CDM,0272,RC,A6530,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,30.36,192.95,,140.29,,,percent of total billed charges,,,,,,,,service not payable,110.78,,,percent of total billed charges,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,,,,,,,service not payable,170.25,,,percent of total billed charges,,,30.36,,,fee schedule,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,147.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,147.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB 5H RT,10585001,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4048.00,1214.40,1570.62,3440.80,,,,,,,,,,,,,,,,,,,,1570.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1720.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3036.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2024.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3440.80,,,percent of total billed charges,,,1821.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB 5H RT,10585001,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4048.00,1214.40,1720.40,3440.80,,,,,,,,,,,,,service not payable,,,,,,,2041.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1720.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3036.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2024.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3036.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3440.80,,,percent of total billed charges,,,1862.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB 11H RT,10585002,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4879.00,1463.70,1893.05,4147.15,,,,,,,,,,,,,,,,,,,,1893.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2073.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3659.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2439.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4147.15,,,percent of total billed charges,,,2195.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB 11H RT,10585002,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4879.00,1463.70,2073.57,4147.15,,,,,,,,,,,,,service not payable,,,,,,,2460.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2073.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3659.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2439.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3659.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4147.15,,,percent of total billed charges,,,2244.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X14MM,10585003,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X14MM,10585003,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW METAPHYSEAL 2.7X14MM,10585004,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW METAPHYSEAL 2.7X14MM,10585004,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP LG EX-FIX COMBO,10585005,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3345.00,1003.50,1297.86,2843.25,,,,,,,,,,,,,,,,,,,,1297.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1421.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2508.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1672.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2843.25,,,percent of total billed charges,,,1505.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LG EX-FIX COMBO,10585005,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3345.00,1003.50,1421.62,2843.25,,,,,,,,,,,,,service not payable,,,,,,,1687.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1421.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2508.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1672.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2508.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2843.25,,,percent of total billed charges,,,1538.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE COMP SS NS 1.6X25X150MM,10585006,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE COMP SS NS 1.6X25X150MM,10585006,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SYS 2ND FIX W SWVLC P,10585007,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SYS 2ND FIX W SWVLC P,10585007,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 35,10585009,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,6066.00,1819.80,2353.61,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2353.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5156.10,,,percent of total billed charges,,,2729.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 35,10585009,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2547.72,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 40,10585010,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,6066.00,1819.80,2353.61,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2353.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5156.10,,,percent of total billed charges,,,2729.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 40,10585010,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2547.72,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 50,10585011,CDM,0278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,6066.00,1819.80,2353.61,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2353.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5156.10,,,percent of total billed charges,,,2729.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LIG ATRICLIP FLEXV LAA 50,10585011,CDM,0278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,6066.00,1819.80,2547.72,5156.10,,2972.34,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2547.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3059.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2578.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4549.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4549.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5156.10,,,percent of total billed charges,,,2790.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT NANO SWIVELOCK 2.5X7MM,10585012,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT NANO SWIVELOCK 2.5X7MM,10585012,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT SWIVELOCK 2.5X7MM,10585013,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT SWIVELOCK 2.5X7MM,10585013,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAK-BB MTP,10585014,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAK-BB MTP,10585014,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT 3X18MM,10585015,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,683.00,204.90,265.00,580.55,,,,,,,,,,,,,,,,,,,,265.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.55,,,percent of total billed charges,,,307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT 3X18MM,10585015,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,683.00,204.90,290.27,580.55,,,,,,,,,,,,,service not payable,,,,,,,344.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,290.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,512.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,580.55,,,percent of total billed charges,,,314.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE COMPRESSION MAXFORCE,10585016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE COMPRESSION MAXFORCE,10585016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MAXFORCE LT 5 DEG,10585017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MAXFORCE LT 5 DEG,10585017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FDL IMPLANT 4.75MM,10585018,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FDL IMPLANT 4.75MM,10585018,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX 21.0D,10585020,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX 21.0D,10585020,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP BONE MR SAFE OPEN ADJ LG,10585023,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3693.00,1107.90,1432.88,3139.05,,,,,,,,,,,,,,,,,,,,1432.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1569.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2769.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1846.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3139.05,,,percent of total billed charges,,,1661.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP BONE MR SAFE OPEN ADJ LG,10585023,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3693.00,1107.90,1569.52,3139.05,,,,,,,,,,,,,service not payable,,,,,,,1862.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1569.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2769.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1846.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2769.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3139.05,,,percent of total billed charges,,,1698.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD LG EX-FIX 11X400MM X_394.87 X_DEPUY ORTHOPAEDI,10585024,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2252.00,675.60,873.78,1914.2,,,,,,,,,,,,,,,,,,,,873.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1689.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1126.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1914.2,,,percent of total billed charges,,,1013.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD LG EX-FIX 11X400MM X_394.87 X_DEPUY ORTHOPAEDI,10585024,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2252.00,675.60,957.10,1914.2,,,,,,,,,,,,,service not payable,,,,,,,1135.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,957.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1689.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1126.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1689.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1914.2,,,percent of total billed charges,,,1035.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD EX-FIX 11X200MM X_394.83 X_DEPUY ORTHOPAEDICS,10585025,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD EX-FIX 11X200MM X_394.83 X_DEPUY ORTHOPAEDICS,10585025,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 3.5X38MM,10587330,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 3.5X38MM,10587330,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD MOD M2A NK 28MM  3MM,10587331,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD MOD M2A NK 28MM  3MM,10587331,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 15X150MM,10587332,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 15X150MM,10587332,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACK CONVENIENCE TIGHTROPE MED,10587423,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5531.00,1659.30,2146.03,4701.35,,2710.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2323.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2146.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2350.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4148.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2765.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4701.35,,,percent of total billed charges,,,2488.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACK CONVENIENCE TIGHTROPE MED,10587423,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5531.00,1659.30,2323.02,4701.35,,2710.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2323.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2789.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2350.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4148.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2765.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4148.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4701.35,,,percent of total billed charges,,,2544.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT KNEE CANN TIB 11X30MM,10587424,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2046.00,613.80,793.85,1739.10,,,,,,,,,,,,,,,,,,,,793.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,869.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1023.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1739.10,,,percent of total billed charges,,,920.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT KNEE CANN TIB 11X30MM,10587424,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2046.00,613.80,869.55,1739.10,,,,,,,,,,,,,service not payable,,,,,,,1032.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,869.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1023.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1739.10,,,percent of total billed charges,,,941.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEMORAL 130D 12X360MM,10587426,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEMORAL 130D 12X360MM,10587426,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEMORAL 130D 11X400MM,10587427,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEMORAL 130D 11X400MM,10587427,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X48MM,10587428,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X48MM,10587428,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X50MM,10587429,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X50MM,10587429,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB 6H DIST RT 95MM,10587430,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2569.00,770.70,996.77,2183.65,,,,,,,,,,,,,,,,,,,,996.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1091.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1926.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1284.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2183.65,,,percent of total billed charges,,,1156.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB 6H DIST RT 95MM,10587430,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2569.00,770.70,1091.82,2183.65,,,,,,,,,,,,,service not payable,,,,,,,1295.8,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1091.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1926.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1284.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1926.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2183.65,,,percent of total billed charges,,,1181.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CRYOPROBE LNG SHAFT 3.8MMX38CM,10587543,CDM,0272,RC,C2618,HCPCS,,,,,,outpatient,facility,,,13113.00,3933.90,5573.02,11146.05,,8103.83,,,percent of total billed charges,,,,,,,,service not payable,6399.14,,,percent of total billed charges,,,6614.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5573.02,,,percent of total billed charges,,,,,,,,,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6556.5,,,percent of total billed charges,,,,,,,,service not payable,9834.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11146.05,,,percent of total billed charges,,,6031.98,,,percent of total billed charges,,,,,,,,,8523.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,8523.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT 2.6MM FBRTAK,10587544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2022.00,606.60,784.54,1718.7,,,,,,,,,,,,,,,,,,,,784.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.7,,,percent of total billed charges,,,909.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT 2.6MM FBRTAK,10587544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2022.00,606.60,859.35,1718.7,,,,,,,,,,,,,service not payable,,,,,,,1019.9,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,859.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1516.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1011.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1516.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1718.7,,,percent of total billed charges,,,930.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST FIB TI RT 4H,10587545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST FIB TI RT 4H,10587545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIB ANT 10X79MM,10587546,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIB ANT 10X79MM,10587546,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CPM 10MMX42CM 125D,10587547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CPM 10MMX42CM 125D,10587547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL CANN TFNA 12X400MM 130DEG,10587548,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL CANN TFNA 12X400MM 130DEG,10587548,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER RINGLOC SIZE 23 28MM,10587549,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER RINGLOC SIZE 23 28MM,10587549,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD ENDO II 55MM,10587551,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD ENDO II 55MM,10587551,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMORAL SZ 17,10587552,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2973.00,891.90,1153.52,2527.05,,,,,,,,,,,,,,,,,,,,1153.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2527.05,,,percent of total billed charges,,,1337.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMORAL SZ 17,10587552,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2973.00,891.90,1263.52,2527.05,,,,,,,,,,,,,service not payable,,,,,,,1499.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1263.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2229.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1486.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2229.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2527.05,,,percent of total billed charges,,,1367.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT URINARY SUSPEND 6X8CM,10587553,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,5059.00,1517.70,1962.89,4300.15,,2478.91,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2124.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,1962.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2150.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3794.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2529.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4300.15,,,percent of total billed charges,,,2276.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT URINARY SUSPEND 6X8CM,10587553,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,5059.00,1517.70,2124.78,4300.15,,2478.91,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2124.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2551.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2150.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3794.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2529.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3794.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4300.15,,,percent of total billed charges,,,2327.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TI 2.7X56MM LONG RIGHT,10587709,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4768.00,1430.40,1849.98,4052.80,,,,,,,,,,,,,,,,,,,,1849.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3576.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2384.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4052.80,,,percent of total billed charges,,,2145.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TI 2.7X56MM LONG RIGHT,10587709,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4768.00,1430.40,2026.40,4052.80,,,,,,,,,,,,,service not payable,,,,,,,2404.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2026.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3576.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2384.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3576.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4052.80,,,percent of total billed charges,,,2193.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X22MM,10587710,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X22MM,10587710,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X26MM,10587711,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X26MM,10587711,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X28MM,10587712,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X28MM,10587712,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X30MM,10587713,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1122.00,336.60,435.34,953.70,,,,,,,,,,,,,,,,,,,,435.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,953.70,,,percent of total billed charges,,,504.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X30MM,10587713,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1122.00,336.60,476.85,953.70,,,,,,,,,,,,,service not payable,,,,,,,565.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,841.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,953.70,,,percent of total billed charges,,,516.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X236MM,10587714,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1122.00,336.60,435.34,953.70,,,,,,,,,,,,,,,,,,,,435.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,953.70,,,percent of total billed charges,,,504.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X236MM,10587714,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1122.00,336.60,476.85,953.70,,,,,,,,,,,,,service not payable,,,,,,,565.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,841.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,841.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,953.70,,,percent of total billed charges,,,516.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X38MM,10587715,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,362.00,108.60,140.46,307.70,,,,,,,,,,,,,,,,,,,,140.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.70,,,percent of total billed charges,,,162.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X38MM,10587715,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,362.00,108.60,153.85,307.70,,,,,,,,,,,,,service not payable,,,,,,,182.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,271.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,307.70,,,percent of total billed charges,,,166.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STAR DRIVE TI 2.7X46MM,10587717,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,362.00,108.60,140.46,307.70,,,,,,,,,,,,,,,,,,,,140.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.70,,,percent of total billed charges,,,162.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STAR DRIVE TI 2.7X46MM,10587717,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,362.00,108.60,153.85,307.70,,,,,,,,,,,,,service not payable,,,,,,,182.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,271.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,307.70,,,percent of total billed charges,,,166.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TI 4.5X54MM,10587718,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1631.00,489.30,632.83,1386.35,,,,,,,,,,,,,,,,,,,,632.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,693.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1223.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,815.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1386.35,,,percent of total billed charges,,,733.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TI 4.5X54MM,10587718,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1631.00,489.30,693.17,1386.35,,,,,,,,,,,,,service not payable,,,,,,,822.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1223.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,815.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1223.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1386.35,,,percent of total billed charges,,,750.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW TI 4.5X72MM,10587719,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1631.00,489.30,632.83,1386.35,,,,,,,,,,,,,,,,,,,,632.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,693.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1223.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,815.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1386.35,,,percent of total billed charges,,,733.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW TI 4.5X72MM,10587719,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1631.00,489.30,693.17,1386.35,,,,,,,,,,,,,service not payable,,,,,,,822.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,693.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1223.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,815.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1223.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1386.35,,,percent of total billed charges,,,750.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE WIRE COMPRSSN 1.6X150MM,10587720,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,385.00,115.50,163.63,327.25,,237.93,,,percent of total billed charges,,,,,,,,service not payable,187.88,,,percent of total billed charges,,,194.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.63,,,percent of total billed charges,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.5,,,percent of total billed charges,,,,,,,,service not payable,288.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,327.25,,,percent of total billed charges,,,177.10,,,percent of total billed charges,,,,,,,,,250.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,250.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATHETER NEPHROLITH 5F 100CM,10587722,CDM,0272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,115.00,34.50,48.88,97.75,,71.07,,,percent of total billed charges,,,,,,,,service not payable,56.12,,,percent of total billed charges,,,58.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,48.88,,,percent of total billed charges,,,,,,,,,86.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,57.5,,,percent of total billed charges,,,,,,,,service not payable,86.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,97.75,,,percent of total billed charges,,,52.90,,,percent of total billed charges,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,74.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CT Exam,10587792,CDM,0351,RC,0042T,CPT,,,,,,outpatient,facility,,,2366.00,709.80,375.0,2011.10,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,service not payable,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,932.0,,,per diem,,,,,,,,,1774.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,service not payable,1774.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2011.10,,,percent of total billed charges,,,1088.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,459.86,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CT Exam,10587792,CDM,0351,RC,0042T,CPT,300,EAPG,,,,outpatient,facility,,,2366.00,709.80,442.27,1068.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,907.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,691.92,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,761.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10587794,CDM,0351,RC,0042T,CPT,,,,,,outpatient,facility,,,2366.00,709.80,375.0,2011.10,,443.74,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 443.74 End FormulaCPE Paid in addition to outpatient services,,,,,,service not payable,375.0,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE,other,,FormulaCPE:  {Units in Service Type} * 375.00 End FormulaCPE Paid in addition to outpatient services,816.74,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  {Units in Service Type} * 842.00 End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,932.0,,,per diem,,,,,,,,,1774.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1097.0,,,per diem,,,,,,,,service not payable,1774.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2011.10,,,percent of total billed charges,,,1088.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,459.86,,,fee schedule,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CT Exam,10587794,CDM,0351,RC,0042T,CPT,300,EAPG,,,,outpatient,facility,,,2366.00,709.80,442.27,1068.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,907.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,442.27,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,691.92,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,761.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INF- IV Infusion bamlanivimab and post admin moni,10587885,CDM,0771,RC,M0245,HCPCS,,,,,,outpatient,facility,,,1016.00,304.80,101.0,863.60,,627.89,,,percent of total billed charges,,,,,,,,service not payable,495.81,,,percent of total billed charges,,,512.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,431.80,,,percent of total billed charges,,,,,,,,,762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.0,,,percent of total billed charges,,,,,,,,service not payable,762.0,,,percent of total billed charges,,,,,,,,,457.20,,,fee schedule,,,,,,,,,863.60,,,percent of total billed charges,,,467.36,,,percent of total billed charges,,,,,,,,,115.0,,,per diem,,,,,,,,service not payable,,,,,,,101.0,,,per diem,,,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
STENT ENDOPROS EXPAND 8X79MM,10587960,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11861.00,3558.30,4602.07,10081.85,,5811.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4981.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4602.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5040.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8895.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5930.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10081.85,,,percent of total billed charges,,,5337.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ENDOPROS EXPAND 8X79MM,10587960,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11861.00,3558.30,4981.62,10081.85,,5811.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4981.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5982.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5040.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8895.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5930.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8895.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10081.85,,,percent of total billed charges,,,5456.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF PERSONA LT 12MM,10587962,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF PERSONA LT 12MM,10587962,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 12X140MM,10587963,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 12X140MM,10587963,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO FX 13MM,10588122,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO FX 13MM,10588122,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE DISTAL CENTRALIZER SZ15 (new),10588123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE DISTAL CENTRALIZER SZ15 (new),10588123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECTOR PRECISION M-1 35CM,10588124,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECTOR PRECISION M-1 35CM,10588124,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT PROCHONDRIX CR 1X13,10588125,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,16811.00,5043.30,6522.67,14289.35,,8237.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7060.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6522.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7144.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12608.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8405.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14289.35,,,percent of total billed charges,,,7564.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT PROCHONDRIX CR 1X13,10588125,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,16811.00,5043.30,7060.62,14289.35,,8237.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7060.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8479.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7144.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12608.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8405.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12608.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14289.35,,,percent of total billed charges,,,7733.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN TRANSFIX 6.0X225MM,10588127,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3345.00,1003.50,1297.86,2843.25,,,,,,,,,,,,,,,,,,,,1297.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1421.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2508.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1672.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2843.25,,,percent of total billed charges,,,1505.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN TRANSFIX 6.0X225MM,10588127,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3345.00,1003.50,1421.62,2843.25,,,,,,,,,,,,,service not payable,,,,,,,1687.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1421.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2508.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1672.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2508.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2843.25,,,percent of total billed charges,,,1538.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SCHANZ S D 4.0/3.0X100M,10588128,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1327.00,398.10,514.88,1127.95,,,,,,,,,,,,,,,,,,,,514.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,563.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,995.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,663.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1127.95,,,percent of total billed charges,,,597.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SCHANZ S D 4.0/3.0X100M,10588128,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1327.00,398.10,563.98,1127.95,,,,,,,,,,,,,service not payable,,,,,,,669.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,563.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,995.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,663.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,995.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1127.95,,,percent of total billed charges,,,610.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM POST STAB N 6N,10588129,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5209.00,1562.70,2021.09,4427.65,,2552.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2187.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2021.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2213.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3906.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2604.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4427.65,,,percent of total billed charges,,,2344.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM POST STAB N 6N,10588129,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5209.00,1562.70,2187.78,4427.65,,2552.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2187.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2627.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2213.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3906.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2604.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3906.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4427.65,,,percent of total billed charges,,,2396.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL 1.6 X 7MM,10588130,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL 1.6 X 7MM,10588130,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL 1.6 X 8MM,10588131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL 1.6 X 8MM,10588131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL 1.6 X 9MM,10588132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL 1.6 X 9MM,10588132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL 1.6 X 10MM,10588133,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL 1.6 X 10MM,10588133,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL 1.6 X 11MM,10588134,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL 1.6 X 11MM,10588134,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL 1.6 X 13MM,10588135,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL 1.6 X 13MM,10588135,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP 2.5 X 50MM MICRO,10588136,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP 2.5 X 50MM MICRO,10588136,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM POST STAB N 4N,10588137,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5239.00,1571.70,2032.73,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2032.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4453.15,,,percent of total billed charges,,,2357.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM POST STAB N 4N,10588137,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5239.00,1571.70,2200.38,4453.15,,2567.11,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2200.38,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2642.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2226.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3929.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2619.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3929.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4453.15,,,percent of total billed charges,,,2409.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CAGE 1.6MM 2X5H,10588138,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CAGE 1.6MM 2X5H,10588138,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LAA 20MM,10588139,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,37154.00,11146.20,14415.75,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14415.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31580.90,,,percent of total billed charges,,,16719.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LAA 20MM,10588139,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,37154.00,11146.20,15604.68,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18740.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31580.90,,,percent of total billed charges,,,17090.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LAA 24MM,10588140,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,37154.00,11146.20,14415.75,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14415.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31580.90,,,percent of total billed charges,,,16719.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LAA 24MM,10588140,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,37154.00,11146.20,15604.68,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18740.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31580.90,,,percent of total billed charges,,,17090.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LAA 27MM,10588141,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,37154.00,11146.20,14415.75,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14415.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31580.90,,,percent of total billed charges,,,16719.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LAA 27MM,10588141,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,37154.00,11146.20,15604.68,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18740.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31580.90,,,percent of total billed charges,,,17090.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LAA 31MM,10588142,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,37154.00,11146.20,14415.75,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14415.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31580.90,,,percent of total billed charges,,,16719.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LAA 31MM,10588142,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,37154.00,11146.20,15604.68,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18740.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31580.90,,,percent of total billed charges,,,17090.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE CLOSE WATCHMAN LAA 35MM,10588143,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,37154.00,11146.20,14415.75,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14415.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31580.90,,,percent of total billed charges,,,16719.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE CLOSE WATCHMAN LAA 35MM,10588143,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,37154.00,11146.20,15604.68,31580.90,,18205.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15604.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,18740.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15790.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18577.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27865.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31580.90,,,percent of total billed charges,,,17090.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
RECORDER LOOP LUX-DX,10588146,CDM,0278,RC,C1764,HCPCS,,,,,,inpatient,facility,,,14752.00,4425.60,5723.78,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5723.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12539.20,,,percent of total billed charges,,,6638.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RECORDER LOOP LUX-DX,10588146,CDM,0278,RC,C1764,HCPCS,,,,,,outpatient,facility,,,14752.00,4425.60,6195.84,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7440.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12539.20,,,percent of total billed charges,,,6785.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS VEGA 17F 4MM,10588147,CDM,0278,RC,L8509,HCPCS,,,,,,inpatient,facility,,,1454.00,436.20,564.15,1235.90,,,,,,,,,,,,,,,,,,,,564.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1090.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,727.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.90,,,percent of total billed charges,,,654.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS VEGA 17F 4MM,10588147,CDM,0278,RC,L8509,HCPCS,,,,,,outpatient,facility,,,1454.00,436.20,90.08,1235.90,,,,,,,,129.07,,,fee schedule,,,,,,,,,733.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,271.52,,,fee schedule,,,90.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",131.65,,,fee schedule,,,296.44,,,fee schedule,,,,,,,,,129.07,,,fee schedule,,,,,,,,,617.95,,,percent of total billed charges,,Paid in addition to outpatient services ,267.59,,,fee schedule,,,1090.5,,,percent of total billed charges,,,129.07,,,fee schedule,,,90.08,,,fee schedule,,,131.65,,,fee schedule,,,727.0,,,percent of total billed charges,,Paid in addition to outpatient services ,129.07,,,fee schedule,,,1090.5,,,percent of total billed charges,,,90.08,,,fee schedule,,,131.65,,,fee schedule,,,,,,,,,1235.90,,,percent of total billed charges,,,668.84,,,percent of total billed charges,,,,,,,,,,,,,,,129.07,,,fee schedule,,,,,,,,,,,,,,,129.07,,,fee schedule,,,,,,,,,130.36,,,fee schedule,,,,,,,,
PLATE LCKG NAR 12H 5.0X223MM,10588148,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7440.00,2232.00,2886.72,6324.0,,3645.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3124.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2886.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3162.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5580.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3720.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6324.0,,,percent of total billed charges,,,3348.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKG NAR 12H 5.0X223MM,10588148,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7440.00,2232.00,3124.80,6324.0,,3645.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3124.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3752.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3162.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5580.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3720.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5580.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6324.0,,,percent of total billed charges,,,3422.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER INSRT ABM PFR PE 61X28MM,10588149,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2784.00,835.20,1080.19,2366.40,,,,,,,,,,,,,,,,,,,,1080.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2366.40,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER INSRT ABM PFR PE 61X28MM,10588149,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2784.00,835.20,1183.2,2366.40,,,,,,,,,,,,,service not payable,,,,,,,1404.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1183.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2088.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1392.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2088.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2366.40,,,percent of total billed charges,,,1280.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP HIP BI MENTUM PFR 61MM,10588150,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4522.00,1356.60,1754.54,3843.70,,,,,,,,,,,,,,,,,,,,1754.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3843.70,,,percent of total billed charges,,,2034.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP HIP BI MENTUM PFR 61MM,10588150,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4522.00,1356.60,1921.85,3843.70,,,,,,,,,,,,,service not payable,,,,,,,2280.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3391.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2261.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3391.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3843.70,,,percent of total billed charges,,,2080.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH LIGHTNING 8 115CM,10588151,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,19047.00,5714.10,8094.98,16189.95,,11771.05,,,percent of total billed charges,,,,,,,,service not payable,9294.94,,,percent of total billed charges,,,9607.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8094.98,,,percent of total billed charges,,,,,,,,,14285.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9523.5,,,percent of total billed charges,,,,,,,,service not payable,14285.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,16189.95,,,percent of total billed charges,,,8761.62,,,percent of total billed charges,,,,,,,,,12380.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,12380.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS AAB MULTIPC NTRL,10588153,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS AAB MULTIPC NTRL,10588153,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TENDON ANTERIOR TIBIALIS,10588154,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7219.00,2165.70,2800.97,6136.15,,3537.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3031.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2800.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3068.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5414.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3609.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6136.15,,,percent of total billed charges,,,3248.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TENDON ANTERIOR TIBIALIS,10588154,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7219.00,2165.70,3031.98,6136.15,,3537.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3031.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3641.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3068.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5414.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3609.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5414.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6136.15,,,percent of total billed charges,,,3320.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE  3.5X32MM X_02.206.232 X_SYNTHES,10588155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE  3.5X32MM X_02.206.232 X_SYNTHES,10588155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKNG 2.7X46MM X_02.211.046 X_SYNTHES,10588156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,673.00,201.90,261.12,572.05,,,,,,,,,,,,,,,,,,,,261.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.05,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKNG 2.7X46MM X_02.211.046 X_SYNTHES,10588156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,673.00,201.90,286.02,572.05,,,,,,,,,,,,,service not payable,,,,,,,339.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,286.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,572.05,,,percent of total billed charges,,,309.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X28MM,10588157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X28MM,10588157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD LG EX-FIX 11MMX350MM X_394.86 X_JOHNSON and JO,10588158,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2054.00,616.20,796.95,1745.90,,,,,,,,,,,,,,,,,,,,796.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,872.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1540.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1027.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1745.90,,,percent of total billed charges,,,924.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD LG EX-FIX 11MMX350MM X_394.86 X_JOHNSON and JO,10588158,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2054.00,616.20,872.95,1745.90,,,,,,,,,,,,,service not payable,,,,,,,1036.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,872.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1540.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1027.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1540.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1745.90,,,percent of total billed charges,,,944.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD LG EX-FIX 11MMX150MM X_394.82 X_JOHNSON and JO,10588159,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1914.00,574.20,742.63,1626.90,,,,,,,,,,,,,,,,,,,,742.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1435.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,957.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.90,,,percent of total billed charges,,,861.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD LG EX-FIX 11MMX150MM X_394.82 X_JOHNSON and JO,10588159,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1914.00,574.20,813.45,1626.90,,,,,,,,,,,,,service not payable,,,,,,,965.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1435.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,957.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1435.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.90,,,percent of total billed charges,,,880.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIBIA 14H RT 2.7/35MM,10588544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9327.00,2798.10,3618.88,7927.95,,4570.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3917.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3618.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3963.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6995.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4663.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7927.95,,,percent of total billed charges,,,4197.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIBIA 14H RT 2.7/35MM,10588544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9327.00,2798.10,3917.34,7927.95,,4570.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3917.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4704.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3963.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6995.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4663.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6995.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7927.95,,,percent of total billed charges,,,4290.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LKING T15 3.5X48MM,10588545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LKING T15 3.5X48MM,10588545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X38MM,10588546,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X38MM,10588546,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X42MM,10588547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X42MM,10588547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X44MM,10588548,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X44MM,10588548,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX STARDIVE 2.7X55MM,10588549,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,305.00,91.50,118.34,259.25,,,,,,,,,,,,,,,,,,,,118.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.25,,,percent of total billed charges,,,137.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX STARDIVE 2.7X55MM,10588549,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,305.00,91.50,129.62,259.25,,,,,,,,,,,,,service not payable,,,,,,,153.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,129.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,228.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,152.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,228.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,259.25,,,percent of total billed charges,,,140.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X30MM,10588550,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X30MM,10588550,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 3.5X28MM,10588551,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2745.00,823.50,1065.06,2333.25,,,,,,,,,,,,,,,,,,,,1065.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2333.25,,,percent of total billed charges,,,1235.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 3.5X28MM,10588551,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2745.00,823.50,1166.62,2333.25,,,,,,,,,,,,,service not payable,,,,,,,1384.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2333.25,,,percent of total billed charges,,,1262.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE 1.4X150MM,10588552,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,654.00,196.20,277.95,555.90,,404.17,,,percent of total billed charges,,,,,,,,service not payable,319.15,,,percent of total billed charges,,,329.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,277.95,,,percent of total billed charges,,,,,,,,,490.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,327.0,,,percent of total billed charges,,,,,,,,service not payable,490.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,555.90,,,percent of total billed charges,,,300.84,,,percent of total billed charges,,,,,,,,,425.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,425.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X24MM,10588556,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X24MM,10588556,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X16MM,10590650,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X16MM,10590650,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT REPAIR FIXATION FIBULINK,10590651,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8392.00,2517.60,3256.10,7133.20,,4112.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3524.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3256.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3566.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7133.20,,,percent of total billed charges,,,3776.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT REPAIR FIXATION FIBULINK,10590651,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8392.00,2517.60,3524.64,7133.20,,4112.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3524.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4232.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3566.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6294.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7133.20,,,percent of total billed charges,,,3860.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT OMEGA 3 4.5X14MM,10590652,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,272.00,81.60,105.54,231.20,,,,,,,,,,,,,,,,,,,,105.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,204.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.20,,,percent of total billed charges,,,122.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT OMEGA 3 4.5X14MM,10590652,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,272.00,81.60,115.60,231.20,,,,,,,,,,,,,service not payable,,,,,,,137.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,115.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,204.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,204.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,231.20,,,percent of total billed charges,,,125.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM LCP 8H 3.5X109MM RT,10590653,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7277.00,2183.10,2823.48,6185.45,,3565.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3056.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2823.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3092.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5457.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3638.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6185.45,,,percent of total billed charges,,,3274.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM LCP 8H 3.5X109MM RT,10590653,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7277.00,2183.10,3056.34,6185.45,,3565.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3056.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3670.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3092.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5457.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3638.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5457.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6185.45,,,percent of total billed charges,,,3347.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 95X10.5MM,10590656,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2486.00,745.80,964.57,2113.10,,,,,,,,,,,,,,,,,,,,964.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2113.10,,,percent of total billed charges,,,1118.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 95X10.5MM,10590656,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,,,,,,,,,,,,service not payable,,,,,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 10MMX34CM 130D LT,10590657,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 10MMX34CM 130D LT,10590657,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER DIST STEM 14MM,10590658,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER DIST STEM 14MM,10590658,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO FX 11X120MM,10590659,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO FX 11X120MM,10590659,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 10MMX32CM 130D LT,10590660,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4443.00,1332.90,1723.88,3776.55,,,,,,,,,,,,,,,,,,,,1723.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1888.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3332.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2221.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3776.55,,,percent of total billed charges,,,1999.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 10MMX32CM 130D LT,10590660,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4443.00,1332.90,1888.27,3776.55,,,,,,,,,,,,,service not payable,,,,,,,2241.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1888.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3332.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2221.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3332.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3776.55,,,percent of total billed charges,,,2043.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE COMP 4LEG 25X20X20MM,10590661,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8001.00,2400.30,3104.39,6800.85,,3920.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3360.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3104.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6000.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4000.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6800.85,,,percent of total billed charges,,,3600.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE COMP 4LEG 25X20X20MM,10590661,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8001.00,2400.30,3360.42,6800.85,,3920.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3360.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4035.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3400.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6000.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4000.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6000.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6800.85,,,percent of total billed charges,,,3680.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 8H LT 3.5X147MM RT,10590662,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8295.00,2488.50,3218.46,7050.75,,4064.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3483.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3218.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3525.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7050.75,,,percent of total billed charges,,,3732.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 8H LT 3.5X147MM RT,10590662,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8295.00,2488.50,3483.90,7050.75,,4064.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3483.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4184.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3525.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7050.75,,,percent of total billed charges,,,3815.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 8H LT 3.5X147MM LT,10590663,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8295.00,2488.50,3218.46,7050.75,,4064.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3483.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3218.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3525.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7050.75,,,percent of total billed charges,,,3732.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 8H LT 3.5X147MM LT,10590663,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8295.00,2488.50,3483.90,7050.75,,4064.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3483.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4184.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3525.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7050.75,,,percent of total billed charges,,,3815.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LOCKING T15 3.5X36MM,10590664,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LOCKING T15 3.5X36MM,10590664,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LOCKING T15 3.5X85MM,10590665,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LOCKING T15 3.5X85MM,10590665,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP LOCKING T15 3.5X90MM,10590666,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP LOCKING T15 3.5X90MM,10590666,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SS ST HEX 3.5X48,10590667,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,60.00,18.00,23.28,51.0,,,,,,,,,,,,,,,,,,,,23.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,45.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.0,,,percent of total billed charges,,,27.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SS ST HEX 3.5X48,10590667,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,60.00,18.00,25.5,51.0,,,,,,,,,,,,,service not payable,,,,,,,30.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,25.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,45.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,30.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,45.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,51.0,,,percent of total billed charges,,,27.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SS ST HEX 3.5X65,10590668,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,169.00,50.70,65.57,143.65,,,,,,,,,,,,,,,,,,,,65.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SS ST HEX 3.5X65,10590668,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,169.00,50.70,71.83,143.65,,,,,,,,,,,,,service not payable,,,,,,,85.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,71.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,126.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,84.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,126.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,143.65,,,percent of total billed charges,,,77.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP LOCKING ST 3.5X90MM,10590669,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,998.00,299.40,387.22,848.30,,,,,,,,,,,,,,,,,,,,387.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,748.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,499.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,848.30,,,percent of total billed charges,,,449.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP LOCKING ST 3.5X90MM,10590669,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,998.00,299.40,424.15,848.30,,,,,,,,,,,,,service not payable,,,,,,,503.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,424.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,748.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,499.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,748.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,848.30,,,percent of total billed charges,,,459.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT HEX 3.5X42MM,10590670,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,169.00,50.70,65.57,143.65,,,,,,,,,,,,,,,,,,,,65.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.83,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT HEX 3.5X42MM,10590670,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,169.00,50.70,71.83,143.65,,,,,,,,,,,,,service not payable,,,,,,,85.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,71.83,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,126.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,84.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,126.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,143.65,,,percent of total billed charges,,,77.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 8F 9MMX15CM,10590671,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13270.00,3981.00,5148.76,11279.5,,6502.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5573.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5148.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5639.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9952.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6635.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11279.5,,,percent of total billed charges,,,5971.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 8F 9MMX15CM,10590671,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13270.00,3981.00,5573.40,11279.5,,6502.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5573.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6693.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5639.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9952.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6635.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9952.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11279.5,,,percent of total billed charges,,,6104.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 8F 10MMX10CM,10590672,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 8F 10MMX10CM,10590672,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10F 11MMX5CM,10590673,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10792.00,3237.60,4187.30,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4187.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9173.20,,,percent of total billed charges,,,4856.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10F 11MMX5CM,10590673,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10792.00,3237.60,4532.64,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5443.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9173.20,,,percent of total billed charges,,,4964.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10F 11MMX10CM,10590674,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10F 11MMX10CM,10590674,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10F 13MMX5CM,10590675,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,10792.00,3237.60,4187.30,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4187.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9173.20,,,percent of total billed charges,,,4856.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10F 13MMX5CM,10590675,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,10792.00,3237.60,4532.64,9173.20,,5288.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4532.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5443.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4586.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8094.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5396.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8094.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9173.20,,,percent of total billed charges,,,4964.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 10F 13MMX10CM,10590676,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11871.00,3561.30,4605.95,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4605.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10090.35,,,percent of total billed charges,,,5341.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 10F 13MMX10CM,10590676,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11871.00,3561.30,4985.82,10090.35,,5816.79,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4985.82,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5987.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5045.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8903.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5935.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8903.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10090.35,,,percent of total billed charges,,,5460.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 7MMX25CM 0.035IN,10590677,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,22463.00,6738.90,8715.64,19093.55,,11006.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9434.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8715.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9546.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16847.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11231.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19093.55,,,percent of total billed charges,,,10108.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 7MMX25CM 0.035IN,10590677,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,22463.00,6738.90,9434.46,19093.55,,11006.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9434.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11330.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9546.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16847.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11231.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16847.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19093.55,,,percent of total billed charges,,,10332.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 7MMX25CM 0.018IN,10590678,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,22246.00,6673.80,8631.45,18909.10,,10900.54,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9343.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8631.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9454.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16684.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11123.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18909.10,,,percent of total billed charges,,,10010.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 7MMX25CM 0.018IN,10590678,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,22246.00,6673.80,9343.32,18909.10,,10900.54,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9343.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11220.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9454.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16684.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11123.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16684.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18909.10,,,percent of total billed charges,,,10233.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 6X19MM 0.035IN,10590679,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9101.00,2730.30,3531.19,7735.85,,4459.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3822.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3531.19,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3867.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6825.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4550.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7735.85,,,percent of total billed charges,,,4095.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 6X19MM 0.035IN,10590679,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9101.00,2730.30,3822.42,7735.85,,4459.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3822.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4590.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3867.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6825.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4550.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6825.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7735.85,,,percent of total billed charges,,,4186.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCP T15 STAR 3.5X38MM,10590680,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCP T15 STAR 3.5X38MM,10590680,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X18MM,10590995,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X18MM,10590995,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X40MM,10590996,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X40MM,10590996,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 3.5X34MM,10590997,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 3.5X34MM,10590997,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MP ST T8STRDRV 2.7X50MM,10590998,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,362.00,108.60,140.46,307.70,,,,,,,,,,,,,,,,,,,,140.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.70,,,percent of total billed charges,,,162.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MP ST T8STRDRV 2.7X50MM,10590998,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,362.00,108.60,153.85,307.70,,,,,,,,,,,,,service not payable,,,,,,,182.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,271.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,181.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,271.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,307.70,,,percent of total billed charges,,,166.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 18X100MM,10590999,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 18X100MM,10590999,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE G DYNANITE 1.1 DBL TIP NI,10591001,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,760.00,228.00,294.88,646.0,,,,,,,,,,,,,,,,,,,,294.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,570.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,380.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.0,,,percent of total billed charges,,,342.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE G DYNANITE 1.1 DBL TIP NI,10591001,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,760.00,228.00,323.0,646.0,,,,,,,,,,,,,service not payable,,,,,,,383.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,323.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,570.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,380.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,570.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,646.0,,,percent of total billed charges,,,349.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Rituxan Therapy Panel,10591536,CDM,0300,RC,86355,CPT,,,,,,outpatient,facility,,,80.00,24.00,35.84,85.27,,80.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,36.98,,,fee schedule,,,80.0,,,fee schedule,,,78.69,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,78.10,,,fee schedule,,,35.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",37.72,,,fee schedule,,,85.27,,,fee schedule,,,,,,,,,36.98,,,fee schedule,,,,,,,,,48.45,,,fee schedule,,,76.97,,,fee schedule,,,60.0,,,percent of total billed charges,,,36.98,,,fee schedule,,,35.84,,,fee schedule,,,37.72,,,fee schedule,,,56.97,,,fee schedule,,,36.98,,,fee schedule,,,60.0,,,percent of total billed charges,,,,,,,,,37.72,,,fee schedule,,,,,,,,,68.0,,,percent of total billed charges,,,36.80,,,percent of total billed charges,,,,,,,,,41.5,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,36.60,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,37.35,,,fee schedule,,,,,,,,
Rituxan Therapy Panel,10591536,CDM,0300,RC,86355,CPT,395,EAPG,,,,outpatient,facility,,,80.00,24.00,48.13,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW PERI SLFTAP 3.5X75MM,10591560,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,242.00,72.60,93.90,205.70,,,,,,,,,,,,,,,,,,,,93.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.70,,,percent of total billed charges,,,108.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERI SLFTAP 3.5X75MM,10591560,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,242.00,72.60,102.85,205.70,,,,,,,,,,,,,service not payable,,,,,,,122.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,102.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,181.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,121.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,181.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,205.70,,,percent of total billed charges,,,111.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP 2.5X11MM,10591563,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP 2.5X11MM,10591563,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB T2 STD 12X375MM,10591564,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6845.00,2053.50,2655.86,5818.25,,3354.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2874.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2655.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2909.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5133.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3422.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5818.25,,,percent of total billed charges,,,3080.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB T2 STD 12X375MM,10591564,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6845.00,2053.50,2874.90,5818.25,,3354.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2874.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3452.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2909.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5133.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3422.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5133.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5818.25,,,percent of total billed charges,,,3148.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CANC CUBE 30ML,10591565,CDM,0278,RC,C9362,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT CANC CUBE 30ML,10591565,CDM,0278,RC,C9362,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT CANC CUBE 30ML,10591565,CDM,0278,RC,C9362,HCPCS,455,EAPG,,,,outpatient,facility,,,3607.00,1082.10,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JOINT FINGER SZ20,10591567,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3919.00,1175.70,1520.57,3331.15,,,,,,,,,,,,,,,,,,,,1520.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1665.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2939.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1959.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3331.15,,,percent of total billed charges,,,1763.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JOINT FINGER SZ20,10591567,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3919.00,1175.70,1665.58,3331.15,,,,,,,,,,,,,service not payable,,,,,,,1976.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1665.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2939.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1959.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2939.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3331.15,,,percent of total billed charges,,,1802.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
JOINT FINGER IMPLANT SZ30,10591568,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3919.00,1175.70,1520.57,3331.15,,,,,,,,,,,,,,,,,,,,1520.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1665.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2939.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1959.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3331.15,,,percent of total billed charges,,,1763.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JOINT FINGER IMPLANT SZ30,10591568,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3919.00,1175.70,1665.58,3331.15,,,,,,,,,,,,,service not payable,,,,,,,1976.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1665.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2939.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1959.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2939.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3331.15,,,percent of total billed charges,,,1802.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE FUSEFORCE KIT 15X15MM,10591569,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6741.00,2022.30,2615.51,5729.85,,3303.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2831.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2615.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2864.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5055.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3370.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5729.85,,,percent of total billed charges,,,3033.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE FUSEFORCE KIT 15X15MM,10591569,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6741.00,2022.30,2831.22,5729.85,,3303.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2831.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3400.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2864.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5055.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3370.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5055.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5729.85,,,percent of total billed charges,,,3100.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT TIBIAL REV SZ5-6 5MM,10591571,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT TIBIAL REV SZ5-6 5MM,10591571,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB CAN TI 11X375MM,10591572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6850.00,2055.00,2657.80,5822.5,,3356.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2877.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2657.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2911.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3425.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5822.5,,,percent of total billed charges,,,3082.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB CAN TI 11X375MM,10591572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6850.00,2055.00,2877.0,5822.5,,3356.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2877.0,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3455.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2911.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5137.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3425.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5137.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5822.5,,,percent of total billed charges,,,3151.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Platelet Pheresis Irradiated E5533,10591627,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5533,10591627,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5533,10591627,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5532/Split,10591628,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5532/Split,10591628,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5532/Split,10591628,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5534,10591629,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5534,10591629,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5534,10591629,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5035/Split,10591630,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5035/Split,10591630,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5035/Split,10591630,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5533/Split,10591631,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5533/Split,10591631,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5533/Split,10591631,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5036,10591632,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5036,10591632,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5036,10591632,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5534/Split,10591633,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5534/Split,10591633,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5534/Split,10591633,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2986/Spl,10591634,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,180.0,367.20,,266.98,,,percent of total billed charges,,,,,,,,,210.82,,,percent of total billed charges,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2986/Spl,10591634,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,432.00,129.60,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2986/Spl,10591634,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,432.00,129.60,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5036/Split,10591635,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5036/Split,10591635,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5036/Split,10591635,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2987,10591636,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,857.00,257.10,180.0,728.45,,529.63,,,percent of total billed charges,,,,,,,,,418.22,,,percent of total billed charges,,,432.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.23,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.5,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.45,,,percent of total billed charges,,,394.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2987,10591636,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,857.00,257.10,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2987,10591636,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,857.00,257.10,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5532,10591637,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5532,10591637,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5532,10591637,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5073,10591638,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5073,10591638,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5073,10591638,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5034,10591639,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5034,10591639,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5034,10591639,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5033/Split,10591640,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5033/Split,10591640,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5033/Split,10591640,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5372/Split,10591641,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5372/Split,10591641,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5372/Split,10591641,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5034/Split,10591642,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5034/Split,10591642,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5034/Split,10591642,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5073/Split,10591643,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5073/Split,10591643,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5073/Split,10591643,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2984,10591644,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,857.00,257.10,180.0,728.45,,529.63,,,percent of total billed charges,,,,,,,,,418.22,,,percent of total billed charges,,,432.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.23,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.5,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.45,,,percent of total billed charges,,,394.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2984,10591644,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,857.00,257.10,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2984,10591644,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,857.00,257.10,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5035,10591645,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5035,10591645,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5035,10591645,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2984/Spl,10591646,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,180.0,367.20,,266.98,,,percent of total billed charges,,,,,,,,,210.82,,,percent of total billed charges,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2984/Spl,10591646,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,432.00,129.60,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2984/Spl,10591646,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,432.00,129.60,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2986,10591647,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,857.00,257.10,180.0,728.45,,529.63,,,percent of total billed charges,,,,,,,,,418.22,,,percent of total billed charges,,,432.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.23,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.5,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.45,,,percent of total billed charges,,,394.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2986,10591647,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,857.00,257.10,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2986,10591647,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,857.00,257.10,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5075,10591648,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5075,10591648,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5075,10591648,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5370,10591649,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5370,10591649,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5370,10591649,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5371,10591651,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5371,10591651,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5371,10591651,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5032,10591652,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5032,10591652,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5032,10591652,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5370/Split,10591653,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5370/Split,10591653,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5370/Split,10591653,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5033,10591654,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5033,10591654,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5033,10591654,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5372,10591655,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5372,10591655,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5372,10591655,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5371/Split,10591656,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5371/Split,10591656,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5371/Split,10591656,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5032/Split,10591657,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5032/Split,10591657,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5032/Split,10591657,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5031/Split,10591658,CDM,0391,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5031/Split,10591658,CDM,0391,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5031/Split,10591658,CDM,0391,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5031,10591659,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5031,10591659,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5031,10591659,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5030/Split,10591660,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5030/Split,10591660,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis E5030/Split,10591660,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis E5030,10591661,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis E5030,10591661,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis E5030,10591661,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5037,10591662,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,958.00,287.40,180.0,814.30,,592.04,,,percent of total billed charges,,,,,,,,,467.5,,,percent of total billed charges,,,483.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.15,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,479.0,,,percent of total billed charges,,,,,,,,,718.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,814.30,,,percent of total billed charges,,,440.68,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5037,10591662,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,958.00,287.40,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5037,10591662,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,958.00,287.40,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2987/Spl,10591663,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,180.0,367.20,,266.98,,,percent of total billed charges,,,,,,,,,210.82,,,percent of total billed charges,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2987/Spl,10591663,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,432.00,129.60,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2987/Spl,10591663,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,432.00,129.60,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irradiated E5037/Split,10591664,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,533.00,159.90,180.0,453.05,,329.39,,,percent of total billed charges,,,,,,,,,260.10,,,percent of total billed charges,,,268.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.53,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,,399.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,,245.18,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irradiated E5037/Split,10591664,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,533.00,159.90,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irradiated E5037/Split,10591664,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,533.00,159.90,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2988,10591665,CDM,0390,RC,P9037,HCPCS,,,,,,outpatient,facility,,,857.00,257.10,180.0,728.45,,529.63,,,percent of total billed charges,,,,,,,,,418.22,,,percent of total billed charges,,,432.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.23,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.5,,,percent of total billed charges,,,,,,,,,642.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.45,,,percent of total billed charges,,,394.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2988,10591665,CDM,0390,RC,P9037,HCPCS,09530,APC,,,,outpatient,facility,,,857.00,257.10,621.49,1526.99,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1398.62,,,fee schedule,,,621.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",678.15,,,fee schedule,,,1526.99,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,1378.35,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,621.49,,,fee schedule,,,678.15,,,fee schedule,,,,,,,,,664.85,,,fee schedule,,,,,,,,,621.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",678.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,,,,,,,664.85,,,fee schedule,,,,,,,,,671.47,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2988,10591665,CDM,0390,RC,P9037,HCPCS,2062,EAPG,,,,outpatient,facility,,,857.00,257.10,401.85,786.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,668.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,401.85,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,458.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,504.68,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Platelet Pheresis Irr Vol Red E2988/Spl,10591666,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,180.0,367.20,,266.98,,,percent of total billed charges,,,,,,,,,210.82,,,percent of total billed charges,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Platelet Pheresis Irr Vol Red E2988/Spl,10591666,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,432.00,129.60,130.43,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,130.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,130.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Platelet Pheresis Irr Vol Red E2988/Spl,10591666,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,432.00,129.60,182.26,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,182.26,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Rituxan Therapy Panel T Cells Total,10591689,CDM,0300,RC,86359,CPT,,,,,,outpatient,facility,,,80.00,24.00,35.84,85.27,,80.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,36.98,,,fee schedule,,,80.0,,,fee schedule,,,78.69,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,78.10,,,fee schedule,,,35.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",37.72,,,fee schedule,,,85.27,,,fee schedule,,,,,,,,,36.98,,,fee schedule,,,,,,,,,48.45,,,fee schedule,,,76.97,,,fee schedule,,,60.0,,,percent of total billed charges,,,36.98,,,fee schedule,,,35.84,,,fee schedule,,,37.72,,,fee schedule,,,56.97,,,fee schedule,,,36.98,,,fee schedule,,,60.0,,,percent of total billed charges,,,,,,,,,37.72,,,fee schedule,,,,,,,,,68.0,,,percent of total billed charges,,,36.80,,,percent of total billed charges,,,,,,,,,41.5,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,36.60,,,fee schedule,,,36.98,,,fee schedule,,,,,,,,,37.35,,,fee schedule,,,,,,,,
Rituxan Therapy Panel T Cells Total,10591689,CDM,0300,RC,86359,CPT,395,EAPG,,,,outpatient,facility,,,80.00,24.00,48.13,121.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,103.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,48.13,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,88.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,97.53,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Auditory-evoked potentials screening w/broadband,10591728,CDM,0471,RC,92650,CPT,,,,,,outpatient,facility,,,700.00,210.00,176.0,595.0,,432.60,,,percent of total billed charges,,,,,,,,service not payable,341.60,,,percent of total billed charges,,,353.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,350.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,350.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,297.5,,,percent of total billed charges,,,,,,,,,525.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,350.0,,,percent of total billed charges,,,,,,,,service not payable,525.0,,,percent of total billed charges,,,,,,,,service not payable,315.0,,,fee schedule,,,,,,,,,595.0,,,percent of total billed charges,,,322.0,,,percent of total billed charges,,,,,,,,,200.0,,,per diem,,,,,,,,service not payable,,,,,,,176.0,,,per diem,,,350.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Auditory-evoked potentials screening w/broadband,10591728,CDM,0471,RC,92650,CPT,229,EAPG,,,,outpatient,facility,,,700.00,210.00,44.39,273.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,232.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,44.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,204.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,225.06,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Auditory evoked potentials  hearing status  broa,10591729,CDM,0471,RC,92651,CPT,,,,,,outpatient,facility,,,440.00,132.00,176.0,374.0,,271.92,,,percent of total billed charges,,,,,,,,,214.72,,,percent of total billed charges,,,221.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,,,,,,,,330.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.0,,,percent of total billed charges,,,,,,,,,330.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,374.0,,,percent of total billed charges,,,202.40,,,percent of total billed charges,,,,,,,,,200.0,,,per diem,,,,,,,,,,,,,,,176.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Auditory evoked potentials  hearing status  broa,10591729,CDM,0471,RC,92651,CPT,05722,APC,,,,outpatient,facility,,,440.00,132.00,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
Auditory evoked potentials  hearing status  broa,10591729,CDM,0471,RC,92651,CPT,257,EAPG,,,,outpatient,facility,,,440.00,132.00,116.19,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,213.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Auditory evoked potentials threshold estimation a,10591730,CDM,0471,RC,92652,CPT,,,,,,outpatient,facility,,,836.00,250.80,176.0,710.60,,516.65,,,percent of total billed charges,,,,,,,,,407.97,,,percent of total billed charges,,,421.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.30,,,percent of total billed charges,,,,,,,,,627.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.0,,,percent of total billed charges,,,,,,,,,627.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,710.60,,,percent of total billed charges,,,384.56,,,percent of total billed charges,,,,,,,,,200.0,,,per diem,,,,,,,,,,,,,,,176.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Auditory evoked potentials threshold estimation a,10591730,CDM,0471,RC,92652,CPT,05722,APC,,,,outpatient,facility,,,836.00,250.80,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
Auditory evoked potentials threshold estimation a,10591730,CDM,0471,RC,92652,CPT,257,EAPG,,,,outpatient,facility,,,836.00,250.80,116.19,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,213.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Auditory evoked potentials neurodiagnostic w/inte,10591731,CDM,0471,RC,92653,CPT,,,,,,outpatient,facility,,,836.00,250.80,176.0,710.60,,516.65,,,percent of total billed charges,,,,,,,,,407.97,,,percent of total billed charges,,,421.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.30,,,percent of total billed charges,,,,,,,,,627.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.0,,,percent of total billed charges,,,,,,,,,627.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,710.60,,,percent of total billed charges,,,384.56,,,percent of total billed charges,,,,,,,,,200.0,,,per diem,,,,,,,,,,,,,,,176.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Auditory evoked potentials neurodiagnostic w/inte,10591731,CDM,0471,RC,92653,CPT,05722,APC,,,,outpatient,facility,,,836.00,250.80,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
Auditory evoked potentials neurodiagnostic w/inte,10591731,CDM,0471,RC,92653,CPT,257,EAPG,,,,outpatient,facility,,,836.00,250.80,116.19,425.60,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,361.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,116.19,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,194.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,213.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TISSUE ALLODERM 10X16CM,10592223,CDM,0278,RC,Q4116,HCPCS,,,,,,inpatient,facility,,,16627.00,4988.10,6451.28,14132.95,,8147.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6983.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6451.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7066.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14132.95,,,percent of total billed charges,,,7482.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE ALLODERM 10X16CM,10592223,CDM,0278,RC,Q4116,HCPCS,,,,,,outpatient,facility,,,16627.00,4988.10,6983.34,16627.0,,8147.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6983.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8386.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7066.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14132.95,,,percent of total billed charges,,,7648.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,16627.0,,,percent of total billed charges,,,,,,,,service not payable,16627.0,,,percent of total billed charges,,
TISSUE ALLODERM 10X16CM,10592223,CDM,0278,RC,Q4116,HCPCS,455,EAPG,,,,outpatient,facility,,,16627.00,4988.10,26.44,31.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,26.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIFESTENT 5F 7 X 100MM X 135CM,10592224,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIFESTENT 5F 7 X 100MM X 135CM,10592224,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIBIA RIGHT 9H,10592225,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4328.00,1298.40,1679.26,3678.80,,,,,,,,,,,,,,,,,,,,1679.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.80,,,percent of total billed charges,,,1947.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIBIA RIGHT 9H,10592225,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4328.00,1298.40,1839.40,3678.80,,,,,,,,,,,,,service not payable,,,,,,,2183.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1839.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3678.80,,,percent of total billed charges,,,1990.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NONLOCK 3.5X28MM,10592226,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,333.00,99.90,129.20,283.05,,,,,,,,,,,,,,,,,,,,129.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,249.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.05,,,percent of total billed charges,,,149.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NONLOCK 3.5X28MM,10592226,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,333.00,99.90,141.53,283.05,,,,,,,,,,,,,service not payable,,,,,,,167.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,141.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,249.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,166.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,249.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,283.05,,,percent of total billed charges,,,153.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NONLOCK 3.5X32MM,10592227,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,333.00,99.90,129.20,283.05,,,,,,,,,,,,,,,,,,,,129.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,249.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.05,,,percent of total billed charges,,,149.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NONLOCK 3.5X32MM,10592227,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,333.00,99.90,141.53,283.05,,,,,,,,,,,,,service not payable,,,,,,,167.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,141.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,249.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,166.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,249.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,283.05,,,percent of total billed charges,,,153.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 4.5X32MM,10592228,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2745.00,823.50,1065.06,2333.25,,,,,,,,,,,,,,,,,,,,1065.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2333.25,,,percent of total billed charges,,,1235.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 4.5X32MM,10592228,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2745.00,823.50,1166.62,2333.25,,,,,,,,,,,,,service not payable,,,,,,,1384.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2333.25,,,percent of total billed charges,,,1262.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADLESS 4.5X55MM,10592229,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2745.00,823.50,1065.06,2333.25,,,,,,,,,,,,,,,,,,,,1065.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2333.25,,,percent of total billed charges,,,1235.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADLESS 4.5X55MM,10592229,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2745.00,823.50,1166.62,2333.25,,,,,,,,,,,,,service not payable,,,,,,,1384.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2333.25,,,percent of total billed charges,,,1262.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT CRAN PARIETAL R FRT,10592230,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,27865.00,8359.50,10811.62,23685.25,,13653.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11703.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10811.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11842.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,20898.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13932.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23685.25,,,percent of total billed charges,,,12539.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT CRAN PARIETAL R FRT,10592230,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,27865.00,8359.50,11703.30,23685.25,,13653.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11703.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,14055.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11842.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,20898.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13932.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,20898.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,23685.25,,,percent of total billed charges,,,12817.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Selective Cath placement 1st order abd/pelvic,10592469,CDM,0481,RC,36245,CPT,,,,,,outpatient,facility,,,1630.00,489.00,749.80,3666.78,,1630.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,3666.78,,,case rate,,,822.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,1222.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,1222.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1385.5,,,percent of total billed charges,,,749.80,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Selective Cath placement 1st order abd/pelvic,10592469,CDM,0481,RC,36245,CPT,423,EAPG,,,,outpatient,facility,,,1630.00,489.00,994.94,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PACEMAKER VALITUTE CRT-P,10592479,CDM,0275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,26216.00,7864.80,10171.81,22283.60,,12845.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11010.72,,,percent of total billed charges,,Paid in addition to inpatient services ,10171.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11141.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19662.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13108.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22283.60,,,percent of total billed charges,,,11797.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER VALITUTE CRT-P,10592479,CDM,0275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,26216.00,7864.80,11010.72,22283.60,,12845.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11010.72,,,percent of total billed charges,,Paid in addition to outpatient services ,13223.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11141.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19662.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13108.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19662.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22283.60,,,percent of total billed charges,,,12059.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL 1 THORACIC 2.3X13MM,10592480,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,913.00,273.90,354.24,776.05,,,,,,,,,,,,,,,,,,,,354.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.05,,,percent of total billed charges,,,410.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL 1 THORACIC 2.3X13MM,10592480,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,913.00,273.90,388.02,776.05,,,,,,,,,,,,,service not payable,,,,,,,460.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,388.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,684.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,456.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,684.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,776.05,,,percent of total billed charges,,,419.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2.0X13MM,10592481,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,374.00,112.20,145.11,317.90,,,,,,,,,,,,,,,,,,,,145.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.90,,,percent of total billed charges,,,168.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2.0X13MM,10592481,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,374.00,112.20,158.95,317.90,,,,,,,,,,,,,service not payable,,,,,,,188.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,280.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,317.90,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2.0X14MM,10592482,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,374.00,112.20,145.11,317.90,,,,,,,,,,,,,,,,,,,,145.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.90,,,percent of total billed charges,,,168.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2.0X14MM,10592482,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,374.00,112.20,158.95,317.90,,,,,,,,,,,,,service not payable,,,,,,,188.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,280.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,317.90,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2.0X15MM,10592483,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,374.00,112.20,145.11,317.90,,,,,,,,,,,,,,,,,,,,145.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.90,,,percent of total billed charges,,,168.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2.0X15MM,10592483,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,374.00,112.20,158.95,317.90,,,,,,,,,,,,,service not payable,,,,,,,188.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,280.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,187.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,280.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,317.90,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN RT 125D 380X12MM,10592611,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN RT 125D 380X12MM,10592611,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 27.0,10592612,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 27.0,10592612,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE REV LAT 39MM 3MM,10592613,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE REV LAT 39MM 3MM,10592613,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT SHOULDER REV 42X9X17.5,10592614,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT SHOULDER REV 42X9X17.5,10592614,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT SHOULDER REV 39X9X12.5,10592615,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT SHOULDER REV 39X9X12.5,10592615,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM FHL IMPLANT 7.0 MM,10592616,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4902.00,1470.60,1901.98,4166.70,,,,,,,,,,,,,,,,,,,,1901.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4166.70,,,percent of total billed charges,,,2205.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM FHL IMPLANT 7.0 MM,10592616,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4902.00,1470.60,2083.35,4166.70,,,,,,,,,,,,,service not payable,,,,,,,2472.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2083.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3676.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2451.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3676.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4166.70,,,percent of total billed charges,,,2254.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFNA LEFT 12MM X 440MM,10592617,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFNA LEFT 12MM X 440MM,10592617,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 12F 65CM,10592619,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,3270.00,981.00,1389.75,2779.5,,2020.86,,,percent of total billed charges,,,,,,,,service not payable,1595.76,,,percent of total billed charges,,,1649.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1389.75,,,percent of total billed charges,,,,,,,,,2452.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1635.0,,,percent of total billed charges,,,,,,,,service not payable,2452.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2779.5,,,percent of total billed charges,,,1504.2,,,percent of total billed charges,,,,,,,,,2125.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2125.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
hs Troponin T - MH/WH/JE,10592660,CDM,0300,RC,84484,CPT,,,,,,outpatient,facility,,,184.00,55.20,11.85,156.40,,41.81,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.22,,,fee schedule,,,31.20,,,fee schedule,,,26.01,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,25.81,,,fee schedule,,,11.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",12.46,,,fee schedule,,,28.18,,,fee schedule,,,,,,,,,12.22,,,fee schedule,,,,,,,,,16.01,,,fee schedule,,,25.44,,,fee schedule,,,138.0,,,percent of total billed charges,,,12.22,,,fee schedule,,,11.85,,,fee schedule,,,12.46,,,fee schedule,,,18.83,,,fee schedule,,,12.22,,,fee schedule,,,138.0,,,percent of total billed charges,,,,,,,,,12.46,,,fee schedule,,,,,,,,,156.40,,,percent of total billed charges,,,84.64,,,percent of total billed charges,,,,,,,,,13.72,,,fee schedule,,,12.22,,,fee schedule,,,,,,,,,12.1,,,fee schedule,,,12.22,,,fee schedule,,,,,,,,,12.34,,,fee schedule,,,,,,,,
hs Troponin T - MH/WH/JE,10592660,CDM,0300,RC,84484,CPT,400,EAPG,,,,outpatient,facility,,,184.00,55.20,14.14,66.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,56.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.60,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,54.56,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SHEATH GUID STR XCUT 8F 45CM,10592712,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,304.67,,,percent of total billed charges,,,,,,,,service not payable,240.58,,,percent of total billed charges,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,320.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,320.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING STR 8F 90CM,10592713,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,503.00,150.90,213.78,427.55,,310.85,,,percent of total billed charges,,,,,,,,service not payable,245.46,,,percent of total billed charges,,,253.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.78,,,percent of total billed charges,,,,,,,,,377.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.5,,,percent of total billed charges,,,,,,,,service not payable,377.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,427.55,,,percent of total billed charges,,,231.38,,,percent of total billed charges,,,,,,,,,326.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,326.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW HEADED 3.0X34MM,10592714,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2366.00,709.80,918.01,2011.10,,,,,,,,,,,,,,,,,,,,918.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1005.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1774.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1183.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2011.10,,,percent of total billed charges,,,1064.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW HEADED 3.0X34MM,10592714,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2366.00,709.80,1005.55,2011.10,,,,,,,,,,,,,service not payable,,,,,,,1193.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1005.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1774.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1183.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1774.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2011.10,,,percent of total billed charges,,,1088.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEEK SPACER AVS 13X25X4,10592715,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6105.00,1831.50,2368.74,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2368.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5189.25,,,percent of total billed charges,,,2747.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEEK SPACER AVS 13X25X4,10592715,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6105.00,1831.50,2564.10,5189.25,,2991.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2564.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3079.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2594.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4578.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3052.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4578.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5189.25,,,percent of total billed charges,,,2808.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY FOLEY 16FR UM STLK,10592820,CDM,0272,RC,A4314,HCPCS,,,,,,outpatient,facility,,,116.00,34.80,49.30,98.60,,71.69,,,percent of total billed charges,,,,,,,,service not payable,56.61,,,percent of total billed charges,,,58.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,49.30,,,percent of total billed charges,,,,,,,,,87.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,58.0,,,percent of total billed charges,,,,,,,,service not payable,87.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,98.60,,,percent of total billed charges,,,53.36,,,percent of total billed charges,,,,,,,,,75.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,75.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH GUIDING SLNDR 6FR 105CM,10592821,CDM,0272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,1650.00,495.00,701.25,1402.5,,1019.7,,,percent of total billed charges,,,,,,,,service not payable,805.20,,,percent of total billed charges,,,832.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,1237.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,825.0,,,percent of total billed charges,,,,,,,,service not payable,1237.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1402.5,,,percent of total billed charges,,,759.0,,,percent of total billed charges,,,,,,,,,1072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1072.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIXATION KIT TOGGLELOC/WASHERL,10592822,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2308.00,692.40,895.50,1961.8,,,,,,,,,,,,,,,,,,,,895.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,980.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1731.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1154.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1961.8,,,percent of total billed charges,,,1038.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIXATION KIT TOGGLELOC/WASHERL,10592822,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2308.00,692.40,980.90,1961.8,,,,,,,,,,,,,service not payable,,,,,,,1164.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,980.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1731.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1154.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1731.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1961.8,,,percent of total billed charges,,,1061.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CANN LT 125D 320X12MM,10592852,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CANN LT 125D 320X12MM,10592852,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W SUPPORT KNOB 5,10592854,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,164.00,49.20,63.63,139.40,,,,,,,,,,,,,,,,,,,,63.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,,73.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPPORT KNOB 5,10592854,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,164.00,49.20,69.70,139.40,,,,,,,,,,,,,service not payable,,,,,,,82.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,69.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SP Exam,10592921,CDM,0361,RC,0620T,CPT,,,,,,outpatient,facility,,,50740.00,15222.00,5463.36,43129.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,25593.26,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,38055.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18583.0,,,case rate,,,,,,,,,38055.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,43129.0,,,percent of total billed charges,,,23340.40,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
SP Exam,10592921,CDM,0361,RC,0620T,CPT,01579,APC,,,,outpatient,facility,,,50740.00,15222.00,33461.41,77088.80,,,,,,,,33461.41,,,fee schedule,,,,,,,,,,,,,,,70607.89,,,fee schedule,,,,,,,,,34130.64,,,fee schedule,,,77088.80,,,fee schedule,,,,,,,,,33461.41,,,fee schedule,,,,,,,,,,,,,,,69584.58,,,fee schedule,,,,,,,,,33461.41,,,fee schedule,,,,,,,,,34130.64,,,fee schedule,,,,,,,,,33461.41,,,fee schedule,,,,,,,,,,,,,,,34130.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33461.41,,,fee schedule,,,,,,,,,,,,,,,33461.41,,,fee schedule,,,,,,,,,33795.69,,,fee schedule,,,,,,,,
SP Exam,10592921,CDM,0361,RC,0620T,CPT,85,EAPG,,,,outpatient,facility,,,50740.00,15222.00,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
BRACE KNEE T SCOPE LG,10593069,CDM,0274,RC,L1832,HCPCS,,,,,,inpatient,facility,,,404.00,121.20,156.75,343.40,,,,,,,,,,,,,,,,,,,,156.75,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,303.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.40,,,percent of total billed charges,,,181.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRACE KNEE T SCOPE LG,10593069,CDM,0274,RC,L1832,HCPCS,,,,,,outpatient,facility,,,404.00,121.20,171.70,913.04,,,,,,,,397.54,,,fee schedule,,,,,,,,,203.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,836.28,,,fee schedule,,,404.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",405.49,,,fee schedule,,,913.04,,,fee schedule,,,,,,,,,397.54,,,fee schedule,,,,,,,,,171.70,,,percent of total billed charges,,Paid in addition to outpatient services ,824.16,,,fee schedule,,,303.0,,,percent of total billed charges,,,397.54,,,fee schedule,,,404.0,,,fee schedule,,,405.49,,,fee schedule,,,202.0,,,percent of total billed charges,,Paid in addition to outpatient services ,397.54,,,fee schedule,,,303.0,,,percent of total billed charges,,,404.0,,,fee schedule,,,405.49,,,fee schedule,,,,,,,,,343.40,,,percent of total billed charges,,,185.84,,,percent of total billed charges,,,,,,,,,,,,,,,397.54,,,fee schedule,,,,,,,,,,,,,,,397.54,,,fee schedule,,,,,,,,,397.54,,,fee schedule,,,,,,,,
CLIP RESOLUTION 360 235CM 17MM,10594472,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1307.00,392.10,507.12,1110.95,,,,,,,,,,,,,,,,,,,,507.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,980.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,653.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1110.95,,,percent of total billed charges,,,588.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLIP RESOLUTION 360 235CM 17MM,10594472,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1307.00,392.10,555.48,1110.95,,,,,,,,,,,,,service not payable,,,,,,,659.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,555.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,980.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,653.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,980.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1110.95,,,percent of total billed charges,,,601.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYS GRAFT MN BDY 25X25X75X95MM,10594474,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,18683.00,5604.90,7249.00,15880.55,,9154.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7846.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7249.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7940.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14012.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15880.55,,,percent of total billed charges,,,8407.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYS GRAFT MN BDY 25X25X75X95MM,10594474,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,18683.00,5604.90,7846.86,15880.55,,9154.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7846.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9423.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7940.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14012.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14012.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15880.55,,,percent of total billed charges,,,8594.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB 4H RT 2.7 VA-LCP,10594475,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3853.00,1155.90,1494.96,3275.05,,,,,,,,,,,,,,,,,,,,1494.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3275.05,,,percent of total billed charges,,,1733.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB 4H RT 2.7 VA-LCP,10594475,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3853.00,1155.90,1637.52,3275.05,,,,,,,,,,,,,service not payable,,,,,,,1943.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1637.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2889.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1926.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2889.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3275.05,,,percent of total billed charges,,,1772.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX 2.7X36MM,10594476,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,137.00,41.10,53.16,116.45,,,,,,,,,,,,,,,,,,,,53.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.45,,,percent of total billed charges,,,61.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX 2.7X36MM,10594476,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,137.00,41.10,58.23,116.45,,,,,,,,,,,,,service not payable,,,,,,,69.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,58.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,102.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,68.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,102.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,63.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 48,10594477,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 48,10594477,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 50,10594478,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 50,10594478,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 55,10594479,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 55,10594479,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 60,10594480,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 60,10594480,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 65,10594481,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 65,10594481,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TIBIA EVOS RT 4H 3.5X70M,10594482,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5744.00,1723.20,2228.67,4882.40,,2814.56,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2412.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2228.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2441.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4308.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2872.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4882.40,,,percent of total billed charges,,,2584.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIBIA EVOS RT 4H 3.5X70M,10594482,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5744.00,1723.20,2412.48,4882.40,,2814.56,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2412.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2897.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2441.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4308.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2872.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4308.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4882.40,,,percent of total billed charges,,,2642.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SET DILATOR URETHRAL FASCIAL,10594484,CDM,0272,RC,C2627,HCPCS,,,,,,outpatient,facility,,,88.00,26.40,37.40,74.80,,54.38,,,percent of total billed charges,,,,,,,,service not payable,42.94,,,percent of total billed charges,,,44.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,37.40,,,percent of total billed charges,,,,,,,,,66.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,44.0,,,percent of total billed charges,,,,,,,,service not payable,66.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,74.80,,,percent of total billed charges,,,40.48,,,percent of total billed charges,,,,,,,,,57.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,57.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM PRSFT LGN 16X220MM,10594486,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5869.00,1760.70,2277.17,4988.65,,2875.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2464.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2277.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2494.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4401.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2934.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4988.65,,,percent of total billed charges,,,2641.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM PRSFT LGN 16X220MM,10594486,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5869.00,1760.70,2464.98,4988.65,,2875.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2464.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2960.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2494.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4401.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2934.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4401.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4988.65,,,percent of total billed charges,,,2699.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE FEM LGN SZ7 15MM,10594487,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5158.00,1547.40,2001.30,4384.30,,2527.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2166.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2001.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2192.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3868.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2579.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4384.30,,,percent of total billed charges,,,2321.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE FEM LGN SZ7 15MM,10594487,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5158.00,1547.40,2166.36,4384.30,,2527.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2166.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2601.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2192.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3868.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2579.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3868.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4384.30,,,percent of total billed charges,,,2372.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ7 RT,10594488,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,25269.00,7580.70,9804.37,21478.65,,12381.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10612.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9804.37,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10739.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18951.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12634.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21478.65,,,percent of total billed charges,,,11371.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ7 RT,10594488,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,25269.00,7580.70,10612.98,21478.65,,12381.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10612.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12745.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10739.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18951.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12634.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18951.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21478.65,,,percent of total billed charges,,,11623.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE W/SCREW FEM 5X5MM SZ7,10594489,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7557.00,2267.10,2932.12,6423.45,,3702.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3173.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2932.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3211.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5667.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3778.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6423.45,,,percent of total billed charges,,,3400.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE W/SCREW FEM 5X5MM SZ7,10594489,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7557.00,2267.10,3173.94,6423.45,,3702.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3173.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3811.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3211.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5667.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3778.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5667.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6423.45,,,percent of total billed charges,,,3476.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE FEM ID 24MM RT,10594490,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21682.00,6504.60,8412.62,18429.70,,10624.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9106.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8412.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9214.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16261.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10841.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18429.70,,,percent of total billed charges,,,9756.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE FEM ID 24MM RT,10594490,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21682.00,6504.60,9106.44,18429.70,,10624.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9106.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10936.4,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9214.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16261.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10841.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16261.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18429.70,,,percent of total billed charges,,,9973.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PRX HUM HI 4H 90MM RT,10594491,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4393.00,1317.90,1704.48,3734.05,,,,,,,,,,,,,,,,,,,,1704.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1867.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3294.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2196.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3734.05,,,percent of total billed charges,,,1976.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PRX HUM HI 4H 90MM RT,10594491,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4393.00,1317.90,1867.02,3734.05,,,,,,,,,,,,,service not payable,,,,,,,2215.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1867.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3294.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2196.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3294.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3734.05,,,percent of total billed charges,,,2020.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OFF 3.5MM SHT MINIBUNION,10594492,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,8274.00,2482.20,3210.31,7032.90,,4054.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3475.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3210.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3516.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6205.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4137.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7032.90,,,percent of total billed charges,,,3723.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OFF 3.5MM SHT MINIBUNION,10594492,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,8274.00,2482.20,3475.08,7032.90,,4054.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3475.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4173.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3516.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4137.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7032.90,,,percent of total billed charges,,,3806.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NL 2.7X14MM MINIBUNION,10594493,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1015.00,304.50,393.82,862.75,,,,,,,,,,,,,,,,,,,,393.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NL 2.7X14MM MINIBUNION,10594493,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1015.00,304.50,431.38,862.75,,,,,,,,,,,,,service not payable,,,,,,,511.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,431.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,761.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,507.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,761.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,862.75,,,percent of total billed charges,,,466.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.0 X 12MM SNAP OFF,10594494,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1566.00,469.80,607.61,1331.10,,,,,,,,,,,,,,,,,,,,607.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,665.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1174.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,783.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1331.10,,,percent of total billed charges,,,704.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.0 X 12MM SNAP OFF,10594494,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1566.00,469.80,665.55,1331.10,,,,,,,,,,,,,service not payable,,,,,,,789.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,665.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1174.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,783.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1174.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1331.10,,,percent of total billed charges,,,720.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DESTINATION 7FR 65CM,10594497,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,493.00,147.90,209.53,419.05,,304.67,,,percent of total billed charges,,,,,,,,service not payable,240.58,,,percent of total billed charges,,,248.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,209.53,,,percent of total billed charges,,,,,,,,,369.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,246.5,,,percent of total billed charges,,,,,,,,service not payable,369.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,419.05,,,percent of total billed charges,,,226.78,,,percent of total billed charges,,,,,,,,,320.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,320.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DESTINATION 7FR 90CM,10594498,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,503.00,150.90,213.78,427.55,,310.85,,,percent of total billed charges,,,,,,,,service not payable,245.46,,,percent of total billed charges,,,253.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,213.78,,,percent of total billed charges,,,,,,,,,377.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,251.5,,,percent of total billed charges,,,,,,,,service not payable,377.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,427.55,,,percent of total billed charges,,,231.38,,,percent of total billed charges,,,,,,,,,326.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,326.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DESTINATION 5FR 45CM,10594499,CDM,0272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,446.00,133.80,189.55,379.10,,275.63,,,percent of total billed charges,,,,,,,,service not payable,217.65,,,percent of total billed charges,,,224.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,,,,,,,334.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,223.0,,,percent of total billed charges,,,,,,,,service not payable,334.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,379.10,,,percent of total billed charges,,,205.16,,,percent of total billed charges,,,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,289.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROVOX VEGA 20FR 8MM,10594500,CDM,0278,RC,L8501,HCPCS,,,,,,inpatient,facility,,,1454.00,436.20,564.15,1235.90,,,,,,,,,,,,,,,,,,,,564.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1090.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,727.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.90,,,percent of total billed charges,,,654.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROVOX VEGA 20FR 8MM,10594500,CDM,0278,RC,L8501,HCPCS,,,,,,outpatient,facility,,,1454.00,436.20,91.24,1235.90,,,,,,,,142.67,,,fee schedule,,,,,,,,,733.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,300.13,,,fee schedule,,,91.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",145.52,,,fee schedule,,,327.68,,,fee schedule,,,,,,,,,142.67,,,fee schedule,,,,,,,,,617.95,,,percent of total billed charges,,Paid in addition to outpatient services ,295.78,,,fee schedule,,,1090.5,,,percent of total billed charges,,,142.67,,,fee schedule,,,91.24,,,fee schedule,,,145.52,,,fee schedule,,,727.0,,,percent of total billed charges,,Paid in addition to outpatient services ,142.67,,,fee schedule,,,1090.5,,,percent of total billed charges,,,91.24,,,fee schedule,,,145.52,,,fee schedule,,,,,,,,,1235.90,,,percent of total billed charges,,,668.84,,,percent of total billed charges,,,,,,,,,,,,,,,142.67,,,fee schedule,,,,,,,,,,,,,,,142.67,,,fee schedule,,,,,,,,,144.10,,,fee schedule,,,,,,,,
SCREW LKG 3.3MM X 24MM,10594503,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1338.00,401.40,519.14,1137.3,,,,,,,,,,,,,,,,,,,,519.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,568.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1003.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,669.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.3,,,percent of total billed charges,,,602.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LKG 3.3MM X 24MM,10594503,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1338.00,401.40,568.65,1137.3,,,,,,,,,,,,,service not payable,,,,,,,674.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,568.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1003.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,669.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1003.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1137.3,,,percent of total billed charges,,,615.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 13MMX34CM 130D LT,10594504,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 13MMX34CM 130D LT,10594504,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DIST TPR RCLM 16X190MM,10596618,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13979.00,4193.70,5423.85,11882.15,,6849.71,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5871.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5423.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5941.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10484.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6989.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11882.15,,,percent of total billed charges,,,6290.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DIST TPR RCLM 16X190MM,10596618,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13979.00,4193.70,5871.18,11882.15,,6849.71,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5871.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7051.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5941.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10484.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6989.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10484.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11882.15,,,percent of total billed charges,,,6430.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI FT 7.3X50MM,10596621,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2028.00,608.40,786.86,1723.8,,,,,,,,,,,,,,,,,,,,786.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1723.8,,,percent of total billed charges,,,912.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI FT 7.3X50MM,10596621,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2028.00,608.40,861.90,1723.8,,,,,,,,,,,,,service not payable,,,,,,,1022.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1723.8,,,percent of total billed charges,,,932.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN TI 7.3X65MM,10596622,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2028.00,608.40,786.86,1723.8,,,,,,,,,,,,,,,,,,,,786.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1723.8,,,percent of total billed charges,,,912.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN TI 7.3X65MM,10596622,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2028.00,608.40,861.90,1723.8,,,,,,,,,,,,,service not payable,,,,,,,1022.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,861.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1521.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1014.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1521.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1723.8,,,percent of total billed charges,,,932.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STARDRIVE TI 2.7X32MM,10596623,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STARDRIVE TI 2.7X32MM,10596623,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STARDRIVE TI 2.7X36MM,10596624,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STARDRIVE TI 2.7X36MM,10596624,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STARDRIVE TI LCKG 2.7X32,10596625,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STARDRIVE TI LCKG 2.7X32,10596625,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STARDRIVE TI LCKG 2.7X34,10596626,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1121.00,336.30,434.95,952.85,,,,,,,,,,,,,,,,,,,,434.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.85,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STARDRIVE TI LCKG 2.7X34,10596626,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1121.00,336.30,476.43,952.85,,,,,,,,,,,,,service not payable,,,,,,,565.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,476.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,840.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,560.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,840.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,952.85,,,percent of total billed charges,,,515.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW STARDROVE TI 2.7X30MM,10596627,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,361.00,108.30,140.07,306.85,,,,,,,,,,,,,,,,,,,,140.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.85,,,percent of total billed charges,,,162.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW STARDROVE TI 2.7X30MM,10596627,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,361.00,108.30,153.42,306.85,,,,,,,,,,,,,service not payable,,,,,,,182.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,153.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,270.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,180.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,270.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,306.85,,,percent of total billed charges,,,166.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE KIRSCHNER 1.6X150MM,10596628,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,831.00,249.30,322.43,706.35,,,,,,,,,,,,,,,,,,,,322.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,623.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.35,,,percent of total billed charges,,,373.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE KIRSCHNER 1.6X150MM,10596628,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,831.00,249.30,353.18,706.35,,,,,,,,,,,,,service not payable,,,,,,,419.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,353.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,623.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,415.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,623.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,706.35,,,percent of total billed charges,,,382.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COROENT ANT TLIF 7X14X34,10596629,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7711.00,2313.30,2991.87,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2991.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6554.35,,,percent of total billed charges,,,3469.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COROENT ANT TLIF 7X14X34,10596629,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7711.00,2313.30,3238.62,6554.35,,3778.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3238.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3889.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3277.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5783.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6554.35,,,percent of total billed charges,,,3547.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE TI 2.7X40MM SHORT LEFT,10596637,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4589.00,1376.70,1780.53,3900.65,,,,,,,,,,,,,,,,,,,,1780.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3441.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2294.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3900.65,,,percent of total billed charges,,,2065.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TI 2.7X40MM SHORT LEFT,10596637,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4589.00,1376.70,1950.32,3900.65,,,,,,,,,,,,,service not payable,,,,,,,2314.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3441.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2294.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3441.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3900.65,,,percent of total billed charges,,,2110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IV Infusion casirivimab/imdevimab w/monitoring,10596794,CDM,0771,RC,M0243,HCPCS,,,,,,outpatient,facility,,,1016.00,304.80,101.0,863.60,,627.89,,,percent of total billed charges,,,,,,,,service not payable,495.81,,,percent of total billed charges,,,512.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,431.80,,,percent of total billed charges,,,,,,,,,762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.0,,,percent of total billed charges,,,,,,,,service not payable,762.0,,,percent of total billed charges,,,,,,,,,457.20,,,fee schedule,,,,,,,,,863.60,,,percent of total billed charges,,,467.36,,,percent of total billed charges,,,,,,,,,115.0,,,per diem,,,,,,,,service not payable,,,,,,,101.0,,,per diem,,,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
INF- IV Infusion casirivimab/imdevimab w/monitorin,10596795,CDM,0771,RC,M0243,HCPCS,,,,,,outpatient,facility,,,1016.00,304.80,101.0,863.60,,627.89,,,percent of total billed charges,,,,,,,,service not payable,495.81,,,percent of total billed charges,,,512.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,431.80,,,percent of total billed charges,,,,,,,,,762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.0,,,percent of total billed charges,,,,,,,,service not payable,762.0,,,percent of total billed charges,,,,,,,,,457.20,,,fee schedule,,,,,,,,,863.60,,,percent of total billed charges,,,467.36,,,percent of total billed charges,,,,,,,,,115.0,,,per diem,,,,,,,,service not payable,,,,,,,101.0,,,per diem,,,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Brachial plexus block continuous infusion,10596869,CDM,0361,RC,64416,CPT,,,,,,outpatient,facility,,,2138.00,641.40,983.48,2912.34,,2138.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1078.41,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1603.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1603.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1817.3,,,percent of total billed charges,,,983.48,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Brachial plexus block continuous infusion,10596869,CDM,0361,RC,64416,CPT,05443,APC,,,,outpatient,facility,,,2138.00,641.40,818.91,1960.87,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1796.01,,,fee schedule,,,818.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",870.84,,,fee schedule,,,1960.87,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,1769.99,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,818.91,,,fee schedule,,,870.84,,,fee schedule,,,,,,,,,853.76,,,fee schedule,,,,,,,,,818.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",870.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,,,,,,,853.76,,,fee schedule,,,,,,,,,862.26,,,fee schedule,,,,,,,,
Brachial plexus block continuous infusion,10596869,CDM,0361,RC,64416,CPT,220,EAPG,,,,outpatient,facility,,,2138.00,641.40,1820.94,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1861.61,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW COMP FT 2.5X38MM,10597048,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X38MM,10597048,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE NITINOL 11WX10L DYNANIT,10597049,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE NITINOL 11WX10L DYNANIT,10597049,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 28.0,10597053,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 28.0,10597053,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE EXPAND ESCALATE,10597054,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3834.00,1150.20,1487.59,3258.90,,,,,,,,,,,,,,,,,,,,1487.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1629.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2875.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1917.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3258.90,,,percent of total billed charges,,,1725.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE EXPAND ESCALATE,10597054,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3834.00,1150.20,1629.45,3258.90,,,,,,,,,,,,,service not payable,,,,,,,1933.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1629.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2875.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1917.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2875.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3258.90,,,percent of total billed charges,,,1763.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SD ESCALATE 2X6MM,10597055,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,672.00,201.60,260.74,571.20,,,,,,,,,,,,,,,,,,,,260.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.20,,,percent of total billed charges,,,302.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SD ESCALATE 2X6MM,10597055,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,672.00,201.60,285.60,571.20,,,,,,,,,,,,,service not payable,,,,,,,338.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,571.20,,,percent of total billed charges,,,309.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SD ESCALATE 2X4MM,10597056,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,672.00,201.60,260.74,571.20,,,,,,,,,,,,,,,,,,,,260.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.20,,,percent of total billed charges,,,302.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SD ESCALATE 2X4MM,10597056,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,672.00,201.60,285.60,571.20,,,,,,,,,,,,,service not payable,,,,,,,338.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,571.20,,,percent of total billed charges,,,309.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SD ESCALATE 2.4X6MM,10597057,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,672.00,201.60,260.74,571.20,,,,,,,,,,,,,,,,,,,,260.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.20,,,percent of total billed charges,,,302.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SD ESCALATE 2.4X6MM,10597057,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,672.00,201.60,285.60,571.20,,,,,,,,,,,,,service not payable,,,,,,,338.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,285.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,571.20,,,percent of total billed charges,,,309.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR PSN LT SZ11,10597058,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR PSN LT SZ11,10597058,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ART SURF PSN LT 10MM,10597059,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ART SURF PSN LT 10MM,10597059,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE VA-LCPSS LG 2.4/2.7MM,10597060,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5301.00,1590.30,2056.79,4505.85,,2597.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2226.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2056.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2252.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3975.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2650.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4505.85,,,percent of total billed charges,,,2385.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE VA-LCPSS LG 2.4/2.7MM,10597060,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5301.00,1590.30,2226.42,4505.85,,2597.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2226.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2673.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2252.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3975.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2650.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3975.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4505.85,,,percent of total billed charges,,,2438.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM LNG RT 13MMX36CM 130D,10597500,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6097.00,1829.10,2365.64,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2365.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5182.45,,,percent of total billed charges,,,2743.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM LNG RT 13MMX36CM 130D,10597500,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6097.00,1829.10,2560.74,5182.45,,2987.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2560.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3075.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2591.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4572.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3048.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4572.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5182.45,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 80X10.5MM,10597501,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2486.00,745.80,964.57,2113.10,,,,,,,,,,,,,,,,,,,,964.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2113.10,,,percent of total billed charges,,,1118.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 80X10.5MM,10597501,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,,,,,,,,,,,,service not payable,,,,,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SHORT RT 10MMX21.5CM 130D,10597502,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4066.00,1219.80,1577.61,3456.10,,,,,,,,,,,,,,,,,,,,1577.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1728.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3049.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2033.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3456.10,,,percent of total billed charges,,,1829.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SHORT RT 10MMX21.5CM 130D,10597502,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4066.00,1219.80,1728.05,3456.10,,,,,,,,,,,,,service not payable,,,,,,,2050.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1728.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3049.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2033.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3049.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3456.10,,,percent of total billed charges,,,1870.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 200MM,10597503,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,44627.00,13388.10,17315.28,37932.95,,21867.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18743.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,17315.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18966.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,33470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37932.95,,,percent of total billed charges,,,20082.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 200MM,10597503,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,44627.00,13388.10,18743.34,37932.95,,21867.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18743.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,22509.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18966.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,33470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,22313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,33470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,37932.95,,,percent of total billed charges,,,20528.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 37 200MM,10597504,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,44627.00,13388.10,17315.28,37932.95,,21867.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18743.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,17315.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18966.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,33470.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22313.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37932.95,,,percent of total billed charges,,,20082.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 37 200MM,10597504,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,44627.00,13388.10,18743.34,37932.95,,21867.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18743.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,22509.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,18966.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,33470.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,22313.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,33470.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,37932.95,,,percent of total billed charges,,,20528.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE XIA 4.5 5.5X55MM,10597514,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2678.00,803.40,1039.06,2276.30,,,,,,,,,,,,,,,,,,,,1039.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2276.30,,,percent of total billed charges,,,1205.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE XIA 4.5 5.5X55MM,10597514,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2678.00,803.40,1138.15,2276.30,,,,,,,,,,,,,service not payable,,,,,,,1350.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2008.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1339.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2008.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2276.30,,,percent of total billed charges,,,1231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK ST VAR ANG 3.5X26MM,10597516,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1192.00,357.60,462.50,1013.2,,,,,,,,,,,,,,,,,,,,462.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.2,,,percent of total billed charges,,,536.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK ST VAR ANG 3.5X26MM,10597516,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1192.00,357.60,506.60,1013.2,,,,,,,,,,,,,service not payable,,,,,,,601.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,506.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,894.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,596.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,894.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1013.2,,,percent of total billed charges,,,548.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RT LA DST 5H 2.7/3.5X121,10597519,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5369.00,1610.70,2083.17,4563.65,,2630.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2254.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2083.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2281.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4026.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2684.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.65,,,percent of total billed charges,,,2416.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RT LA DST 5H 2.7/3.5X121,10597519,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5369.00,1610.70,2254.98,4563.65,,2630.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2254.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2708.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2281.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4026.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2684.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4026.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4563.65,,,percent of total billed charges,,,2469.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM LCP RT 2.7-3.5X72MM,10597520,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5540.00,1662.00,2149.52,4709.0,,2714.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2326.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2149.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4155.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2770.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4709.0,,,percent of total billed charges,,,2493.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM LCP RT 2.7-3.5X72MM,10597520,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5540.00,1662.00,2326.80,4709.0,,2714.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2326.80,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2794.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2354.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4155.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2770.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4155.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4709.0,,,percent of total billed charges,,,2548.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STAPLE SUPERMAX 25WX20L NHPL,10597521,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6869.00,2060.70,2665.17,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2665.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5838.65,,,percent of total billed charges,,,3091.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE SUPERMAX 25WX20L NHPL,10597521,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6869.00,2060.70,2884.98,5838.65,,3365.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2884.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3464.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2919.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5151.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3434.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5151.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5838.65,,,percent of total billed charges,,,3159.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE NCB 5H DIST RT 167MM,10597522,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4016.00,1204.80,1558.21,3413.60,,,,,,,,,,,,,,,,,,,,1558.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1706.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3012.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,,1807.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE NCB 5H DIST RT 167MM,10597522,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4016.00,1204.80,1706.8,3413.60,,,,,,,,,,,,,service not payable,,,,,,,2025.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1706.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3012.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3012.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,,1847.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FIBERTAK RC DBLOAD TAPE BL/W,10597524,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIBERTAK RC DBLOAD TAPE BL/W,10597524,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT ALLOGRAFT OATS,10597525,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT ALLOGRAFT OATS,10597525,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cortisol Dexamethasone Suppression,10599006,CDM,0300,RC,82533,CPT,,,,,,outpatient,facility,,,131.00,39.30,15.49,111.35,,57.21,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,15.97,,,fee schedule,,,42.69,,,fee schedule,,,34.0,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,33.74,,,fee schedule,,,15.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",16.29,,,fee schedule,,,36.84,,,fee schedule,,,,,,,,,15.97,,,fee schedule,,,,,,,,,21.06,,,fee schedule,,,33.25,,,fee schedule,,,98.25,,,percent of total billed charges,,,15.97,,,fee schedule,,,15.49,,,fee schedule,,,16.29,,,fee schedule,,,24.77,,,fee schedule,,,15.97,,,fee schedule,,,98.25,,,percent of total billed charges,,,,,,,,,16.29,,,fee schedule,,,,,,,,,111.35,,,percent of total billed charges,,,60.26,,,percent of total billed charges,,,,,,,,,17.93,,,fee schedule,,,15.97,,,fee schedule,,,,,,,,,15.81,,,fee schedule,,,15.97,,,fee schedule,,,,,,,,,16.13,,,fee schedule,,,,,,,,
Cortisol Dexamethasone Suppression,10599006,CDM,0300,RC,82533,CPT,398,EAPG,,,,outpatient,facility,,,131.00,39.30,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT TISSUE THICK 3X7CM,10599010,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,3559.00,1067.70,1380.89,3025.15,,,,,,,,,,,,,,,,,,,,1380.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2669.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1779.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3025.15,,,percent of total billed charges,,,1601.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT TISSUE THICK 3X7CM,10599010,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,3559.00,1067.70,1512.58,3025.15,,,,,,,,,,,,,service not payable,,,,,,,1795.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1512.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2669.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1779.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2669.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3025.15,,,percent of total billed charges,,,1637.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER SPINE 4DEG 12X22X30MM,10599014,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,14458.00,4337.40,5609.70,12289.30,,7084.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6072.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5609.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6144.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10843.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7229.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12289.30,,,percent of total billed charges,,,6506.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER SPINE 4DEG 12X22X30MM,10599014,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,14458.00,4337.40,6072.36,12289.30,,7084.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6072.36,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7292.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6144.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10843.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7229.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10843.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12289.30,,,percent of total billed charges,,,6650.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN CVRD 10MMX15CM,10599015,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13270.00,3981.00,5148.76,11279.5,,6502.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5573.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5148.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5639.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9952.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6635.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11279.5,,,percent of total billed charges,,,5971.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN CVRD 10MMX15CM,10599015,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13270.00,3981.00,5573.40,11279.5,,6502.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5573.40,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6693.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5639.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9952.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6635.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9952.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11279.5,,,percent of total billed charges,,,6104.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TRIATHLON CR X3 TIB 9MM,10599016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TRIATHLON CR X3 TIB 9MM,10599016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 4X24MM,10599017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2708.00,812.40,1050.70,2301.80,,,,,,,,,,,,,,,,,,,,1050.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,,1218.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 4X24MM,10599017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2708.00,812.40,1150.90,2301.80,,,,,,,,,,,,,service not payable,,,,,,,1365.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,,1245.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Select cath plcmnt 2nd order abd/pelvic or low e,10599369,CDM,0481,RC,36246,CPT,,,,,,outpatient,facility,,,1651.00,495.30,759.46,3666.78,,1651.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,3666.78,,,case rate,,,832.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,1238.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,1238.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1403.35,,,percent of total billed charges,,,759.46,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Select cath plcmnt 2nd order abd/pelvic or low e,10599369,CDM,0481,RC,36246,CPT,423,EAPG,,,,outpatient,facility,,,1651.00,495.30,994.94,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,994.94,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Transcath therapy thrombolysis initial venous inf,10599373,CDM,0450,RC,37212,CPT,,,,,,outpatient,facility,,,5486.00,1645.80,774.0,4663.10,,3390.35,,,percent of total billed charges,,,,,,,,,2677.17,,,percent of total billed charges,,,2767.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4114.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4114.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4663.10,,,percent of total billed charges,,,2523.56,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Transcath therapy thrombolysis initial venous inf,10599373,CDM,0450,RC,37212,CPT,05183,APC,,,,outpatient,facility,,,5486.00,1645.80,1447.58,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,1447.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,1447.58,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,1447.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Transcath therapy thrombolysis initial venous inf,10599373,CDM,0450,RC,37212,CPT,77,EAPG,,,,outpatient,facility,,,5486.00,1645.80,5360.09,12010.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12010.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,10209.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6296.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,6925.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
STENT ESOPHAGEAL 14MM X 6 CM,10599491,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9507.00,2852.10,3688.72,8080.95,,4658.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3992.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3688.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7130.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4753.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8080.95,,,percent of total billed charges,,,4278.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ESOPHAGEAL 14MM X 6 CM,10599491,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9507.00,2852.10,3992.94,8080.95,,4658.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3992.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4795.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4040.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7130.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4753.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7130.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8080.95,,,percent of total billed charges,,,4373.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STNT ESOPHGL FLLY CVRD18MMX6CM,10599492,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9507.00,2852.10,3688.72,8080.95,,4658.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3992.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3688.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7130.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4753.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8080.95,,,percent of total billed charges,,,4278.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STNT ESOPHGL FLLY CVRD18MMX6CM,10599492,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9507.00,2852.10,3992.94,8080.95,,4658.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3992.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4795.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4040.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7130.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4753.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7130.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8080.95,,,percent of total billed charges,,,4373.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BODY PROXIMAL SZ14 128DEG,10599493,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BODY PROXIMAL SZ14 128DEG,10599493,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM GLBL UNITE 56X21MM,10599494,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM GLBL UNITE 56X21MM,10599494,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL FX 12MM,10599495,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,29812.00,8943.60,11567.06,25340.20,,14607.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12521.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,11567.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12670.1,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,22359.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14906.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25340.20,,,percent of total billed charges,,,13415.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL FX 12MM,10599495,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,29812.00,8943.60,12521.04,25340.20,,14607.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12521.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15037.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,12670.1,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,22359.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,14906.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,22359.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,25340.20,,,percent of total billed charges,,,13713.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL TSA SR 56X22MM,10599496,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12042.00,3612.60,4672.30,10235.70,,5900.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5057.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4672.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5117.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9031.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6021.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10235.70,,,percent of total billed charges,,,5418.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL TSA SR 56X22MM,10599496,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12042.00,3612.60,5057.64,10235.70,,5900.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5057.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6073.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5117.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9031.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6021.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9031.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10235.70,,,percent of total billed charges,,,5539.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFN CANN 130D 440MM,10599497,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFN CANN 130D 440MM,10599497,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TFN CANN 130D LT 10X400MM,10599498,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10702.00,3210.60,4152.38,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4152.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9096.70,,,percent of total billed charges,,,4815.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TFN CANN 130D LT 10X400MM,10599498,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10702.00,3210.60,4494.84,9096.70,,5243.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4494.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5398.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4548.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8026.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5351.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8026.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9096.70,,,percent of total billed charges,,,4922.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC PT SM HEX 4X50MM,10599499,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,181.00,54.30,70.23,153.85,,,,,,,,,,,,,,,,,,,,70.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.85,,,percent of total billed charges,,,81.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC PT SM HEX 4X50MM,10599499,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,181.00,54.30,76.92,153.85,,,,,,,,,,,,,service not payable,,,,,,,91.30,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,76.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,135.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,90.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,135.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,153.85,,,percent of total billed charges,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT ESOPHAGEAL AGILE 14X62MM,10599500,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,8147.00,2444.10,3161.04,6924.95,,3992.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3421.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3161.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3462.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6110.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4073.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6924.95,,,percent of total billed charges,,,3666.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT ESOPHAGEAL AGILE 14X62MM,10599500,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,8147.00,2444.10,3421.74,6924.95,,3992.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3421.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4109.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3462.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6110.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4073.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6110.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6924.95,,,percent of total billed charges,,,3747.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Injection anesthetic agent or steroid Femoral Nerv,10599650,CDM,0450,RC,64447,CPT,,,,,,outpatient,facility,,,1223.00,366.90,562.58,1039.55,,755.81,,,percent of total billed charges,,,,,,,,,596.82,,,percent of total billed charges,,,616.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.55,,,percent of total billed charges,,,562.58,,,percent of total billed charges,,,,,,,,,880.0,,,case rate,,,,,,,,,,,,,,,774.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Injection anesthetic agent or steroid Femoral Nerv,10599650,CDM,0450,RC,64447,CPT,05442,APC,,,,outpatient,facility,,,1223.00,366.90,318.5,1525.27,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1397.04,,,fee schedule,,,318.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (50.00% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (50.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above ",677.38,,,fee schedule,,,1525.27,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,1376.80,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,318.5,,,fee schedule,,,677.38,,,fee schedule,,,,,,,,,664.10,,,fee schedule,,,,,,,,,318.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD ER ROOM TRIAGE PROCS]: (100.00% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 50.00% of Medicare total payment     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Ignore Off Campus Pricing Logic     Alternate APC ",677.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,,,,,,,664.10,,,fee schedule,,,,,,,,,670.72,,,fee schedule,,,,,,,,
Injection anesthetic agent or steroid Femoral Nerv,10599650,CDM,0450,RC,64447,CPT,220,EAPG,,,,outpatient,facility,,,1223.00,366.90,1223.0,7315.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7315.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,6218.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1223.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1820.94,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2003.03,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INSERT TIBIAL TRIATHLON PS X3,10599668,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL TRIATHLON PS X3,10599668,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN XTRAFIX SLFDRL 2.5X80X20MM,10599669,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,738.00,221.40,286.34,627.30,,,,,,,,,,,,,,,,,,,,286.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,332.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN XTRAFIX SLFDRL 2.5X80X20MM,10599669,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,,,,,,,,,,,,service not payable,,,,,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CLAMP PIN SYS XTRAFIX EXT SM,10599670,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3622.00,1086.60,1405.34,3078.70,,,,,,,,,,,,,,,,,,,,1405.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3078.70,,,percent of total billed charges,,,1629.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP PIN SYS XTRAFIX EXT SM,10599670,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3622.00,1086.60,1539.35,3078.70,,,,,,,,,,,,,service not payable,,,,,,,1826.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1539.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2716.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1811.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2716.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3078.70,,,percent of total billed charges,,,1666.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN SMALL 4 X 120 X 25,10599671,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,738.00,221.40,286.34,627.30,,,,,,,,,,,,,,,,,,,,286.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,,332.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN SMALL 4 X 120 X 25,10599671,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,,,,,,,,,,,,service not payable,,,,,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BAR CARB FIB XTRAFIX EXT 250X6,10599672,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1175.00,352.50,455.90,998.75,,,,,,,,,,,,,,,,,,,,455.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,499.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,881.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,587.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,,528.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BAR CARB FIB XTRAFIX EXT 250X6,10599672,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1175.00,352.50,499.38,998.75,,,,,,,,,,,,,service not payable,,,,,,,592.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,499.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,881.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,587.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,881.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,,540.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CENTRALIZER DIST HIP STEM 9MM,10599673,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CENTRALIZER DIST HIP STEM 9MM,10599673,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK HIP VERSYS SZ 13/15X20MM,10599674,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2268.00,680.40,879.98,1927.8,,,,,,,,,,,,,,,,,,,,879.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,963.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1701.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1134.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1927.8,,,percent of total billed charges,,,1020.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK HIP VERSYS SZ 13/15X20MM,10599674,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2268.00,680.40,963.90,1927.8,,,,,,,,,,,,,service not payable,,,,,,,1143.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,963.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1701.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1134.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1701.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1927.8,,,percent of total billed charges,,,1043.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM HIP VERSYS 13X210MM,10599675,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,15835.00,4750.50,6143.98,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6143.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13459.75,,,percent of total billed charges,,,7125.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM HIP VERSYS 13X210MM,10599675,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,15835.00,4750.50,6650.70,13459.75,,7759.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6650.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7987.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6729.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11876.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11876.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13459.75,,,percent of total billed charges,,,7284.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP VERSYS 12/14X46MM,10599676,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP VERSYS 12/14X46MM,10599676,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FUSION 1.5MM/TH SM LT,10599677,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5498.00,1649.40,2133.22,4673.30,,2694.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2309.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2133.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2336.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2749.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4673.30,,,percent of total billed charges,,,2474.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FUSION 1.5MM/TH SM LT,10599677,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5498.00,1649.40,2309.16,4673.30,,2694.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2309.16,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2773.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2336.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4123.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2749.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4673.30,,,percent of total billed charges,,,2529.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING PLATE 4.2X32MM,10599678,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1083.00,324.90,420.20,920.55,,,,,,,,,,,,,,,,,,,,420.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920.55,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING PLATE 4.2X32MM,10599678,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1083.00,324.90,460.27,920.55,,,,,,,,,,,,,service not payable,,,,,,,546.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,460.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,812.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,541.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,812.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,920.55,,,percent of total billed charges,,,498.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HDLS ST MM 4.0X36MM,10599679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1492.00,447.60,578.90,1268.2,,,,,,,,,,,,,,,,,,,,578.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,634.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1119.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,746.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1268.2,,,percent of total billed charges,,,671.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HDLS ST MM 4.0X36MM,10599679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1492.00,447.60,634.10,1268.2,,,,,,,,,,,,,service not payable,,,,,,,752.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,634.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1119.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,746.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1119.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1268.2,,,percent of total billed charges,,,686.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID 25D SML AUG RT,10599680,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8560.00,2568.00,3321.28,7276.0,,4194.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3595.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3321.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3638.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6420.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4280.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7276.0,,,percent of total billed charges,,,3852.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID 25D SML AUG RT,10599680,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8560.00,2568.00,3595.20,7276.0,,4194.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3595.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4317.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3638.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6420.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4280.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6420.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7276.0,,,percent of total billed charges,,,3937.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GAUGE DEPTH TOGGLELOC,10599681,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1933.00,579.90,750.00,1643.05,,,,,,,,,,,,,,,,,,,,750.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,821.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1449.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,966.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1643.05,,,percent of total billed charges,,,869.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GAUGE DEPTH TOGGLELOC,10599681,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1933.00,579.90,821.52,1643.05,,,,,,,,,,,,,service not payable,,,,,,,975.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,821.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1449.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,966.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1449.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1643.05,,,percent of total billed charges,,,889.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL SHOULDER 7X83MM,10599776,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL SHOULDER 7X83MM,10599776,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH .018 OTW 130CM 5X100MM,10599777,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,2937.97,,,percent of total billed charges,,,,,,,,service not payable,2319.95,,,percent of total billed charges,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2377.0,,,percent of total billed charges,,,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,3090.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3090.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH .018 OTW 130CM 6X100MM,10599778,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,7377.00,2213.10,3135.22,6270.45,,4558.99,,,percent of total billed charges,,,,,,,,service not payable,3599.98,,,percent of total billed charges,,,3720.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3135.22,,,percent of total billed charges,,,,,,,,,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,5532.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6270.45,,,percent of total billed charges,,,3393.42,,,percent of total billed charges,,,,,,,,,4795.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,4795.05,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO NB ADV ANG 5F 65CM,10599981,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO NB ADV ANG 5F 100CM X_HNB5.0-38-100-P-N,10599982,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO NB ADV 12H 5F 100CM,10599983,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANGIO NB ADV C1 5F 65CM X_HNB5.0-38-65-P-NS-C,10599984,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
JOINT FINGER SZ30,10599985,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3919.00,1175.70,1520.57,3331.15,,,,,,,,,,,,,,,,,,,,1520.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1665.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2939.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1959.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3331.15,,,percent of total billed charges,,,1763.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JOINT FINGER SZ30,10599985,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3919.00,1175.70,1665.58,3331.15,,,,,,,,,,,,,service not payable,,,,,,,1976.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1665.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2939.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1959.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2939.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3331.15,,,percent of total billed charges,,,1802.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE TROCAR 1.1MM .45IN,10599987,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,service not payable,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN BONE BB-TAK SM,10599988,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN BONE BB-TAK SM,10599988,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDESCOPE BFLEX BRONCHO 5.8MM,10599989,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1700.00,510.00,659.60,1445.0,,,,,,,,,,,,,,,,,,,,659.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1275.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,850.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1445.0,,,percent of total billed charges,,,765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDESCOPE BFLEX BRONCHO 5.8MM,10599989,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1700.00,510.00,722.5,1445.0,,,,,,,,,,,,,service not payable,,,,,,,857.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,722.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1275.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,850.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1275.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1445.0,,,percent of total billed charges,,,782.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 10MM 79/83MM,10599990,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 10MM 79/83MM,10599990,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 32.0,10599991,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,870.00,261.00,337.56,739.5,,,,,,,,,,,,,,,,,,,,337.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,652.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,435.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 32.0,10599991,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,870.00,261.00,369.75,739.5,,,,,,,,,,,,,service not payable,,,,,,,438.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,369.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,652.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,435.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,652.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,739.5,,,percent of total billed charges,,,400.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE NEAR CORT 2.4X22MM,10599993,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE NEAR CORT 2.4X22MM,10599993,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GWIRE AMPLATZ APEX 0.035INX260,10599994,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,183.60,367.20,,266.98,,,percent of total billed charges,,,,,,,,service not payable,210.82,,,percent of total billed charges,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,183.60,,,percent of total billed charges,,,,,,,,,324.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,216.0,,,percent of total billed charges,,,,,,,,service not payable,324.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,280.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,280.80,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORTICAL TI 1.4X7MM,10599995,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORTICAL TI 1.4X7MM,10599995,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORTICAL TI 1.4X8MM,10599996,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORTICAL TI 1.4X8MM,10599996,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORTICAL TI 1.4X9MM,10599997,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORTICAL TI 1.4X9MM,10599997,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE HOOK 1.4MM,10599998,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2158.00,647.40,837.30,1834.3,,,,,,,,,,,,,,,,,,,,837.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1834.3,,,percent of total billed charges,,,971.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE HOOK 1.4MM,10599998,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2158.00,647.40,917.15,1834.3,,,,,,,,,,,,,service not payable,,,,,,,1088.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,917.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1618.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1079.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1618.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1834.3,,,percent of total billed charges,,,992.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
T-PLATE 1.4MM 8 HOLE,10599999,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
T-PLATE 1.4MM 8 HOLE,10599999,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LOCKING 1.4X7MM,10600000,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LOCKING 1.4X7MM,10600000,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LOCKING 1.4X8MM,10600001,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LOCKING 1.4X8MM,10600001,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LOCKING 1.4X9MM,10600002,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LOCKING 1.4X9MM,10600002,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VA LOCKING 1.4X13MM,10600003,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VA LOCKING 1.4X13MM,10600003,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEFIB MOMENTUM CRT-D FAIL DEV,10600004,CDM,0278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,51468.00,15440.40,19969.58,43747.80,,25219.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,21616.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,19969.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21873.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,38601.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25734.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43747.80,,,percent of total billed charges,,,23160.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEFIB MOMENTUM CRT-D FAIL DEV,10600004,CDM,0278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,51468.00,15440.40,21616.56,43747.80,,25219.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,21616.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,25960.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,21873.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,38601.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,25734.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,38601.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,43747.80,,,percent of total billed charges,,,23675.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TRIGEN 9MMX42CM RT,10600281,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12262.00,3678.60,4757.66,10422.70,,6008.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5150.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4757.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5211.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9196.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6131.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10422.70,,,percent of total billed charges,,,5517.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TRIGEN 9MMX42CM RT,10600281,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12262.00,3678.60,5150.04,10422.70,,6008.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5150.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6184.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5211.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9196.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6131.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9196.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10422.70,,,percent of total billed charges,,,5640.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCK ST 2.5MM,10600282,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1991.00,597.30,772.51,1692.35,,,,,,,,,,,,,,,,,,,,772.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1493.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,995.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1692.35,,,percent of total billed charges,,,895.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCK ST 2.5MM,10600282,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1991.00,597.30,846.17,1692.35,,,,,,,,,,,,,service not payable,,,,,,,1004.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,846.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1493.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,995.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1493.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1692.35,,,percent of total billed charges,,,915.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEG FT 2.5MMX12MM,10600283,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEG FT 2.5MMX12MM,10600283,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEG FT 2.5MMX13MM,10600284,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,422.00,126.60,163.74,358.70,,,,,,,,,,,,,,,,,,,,163.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.70,,,percent of total billed charges,,,189.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEG FT 2.5MMX13MM,10600284,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,422.00,126.60,179.35,358.70,,,,,,,,,,,,,service not payable,,,,,,,212.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,179.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,211.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,316.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,358.70,,,percent of total billed charges,,,194.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK 2.7X12MM,10600286,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,323.00,96.90,125.32,274.55,,,,,,,,,,,,,,,,,,,,125.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.55,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK 2.7X12MM,10600286,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,,,,,,,,,,,,service not payable,,,,,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK 2.7X20MM,10600287,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,323.00,96.90,125.32,274.55,,,,,,,,,,,,,,,,,,,,125.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.55,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK 2.7X20MM,10600287,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,,,,,,,,,,,,service not payable,,,,,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM 10MMX36CM LT 130DEG,10600288,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM 10MMX36CM LT 130DEG,10600288,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG 10.5X85MM,10600289,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2339.00,701.70,907.53,1988.15,,,,,,,,,,,,,,,,,,,,907.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1754.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1169.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1988.15,,,percent of total billed charges,,,1052.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG 10.5X85MM,10600289,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2339.00,701.70,994.07,1988.15,,,,,,,,,,,,,service not payable,,,,,,,1179.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,994.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1754.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1169.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1754.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1988.15,,,percent of total billed charges,,,1075.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 20.0,10600290,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 20.0,10600290,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE SPINE MOD SERV 6X16X12MM,10600291,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE SPINE MOD SERV 6X16X12MM,10600291,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW OSTEOPENIA FT 4X22MM,10600292,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,432.00,129.60,167.62,367.20,,,,,,,,,,,,,,,,,,,,167.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,194.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW OSTEOPENIA FT 4X22MM,10600292,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,183.60,367.20,,,,,,,,,,,,,service not payable,,,,,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,183.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,324.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,216.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,324.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW OSTEOPENIA FT 4X30MM,10600293,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,432.00,129.60,167.62,367.20,,,,,,,,,,,,,,,,,,,,167.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,194.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW OSTEOPENIA FT 4X30MM,10600293,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,183.60,367.20,,,,,,,,,,,,,service not payable,,,,,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,183.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,324.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,216.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,324.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW OSTEOPENIA FT 4X34MM,10600294,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,432.00,129.60,167.62,367.20,,,,,,,,,,,,,,,,,,,,167.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,324.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,216.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,,194.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW OSTEOPENIA FT 4X34MM,10600294,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,432.00,129.60,183.60,367.20,,,,,,,,,,,,,service not payable,,,,,,,217.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,183.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,324.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,216.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,324.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,,198.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 20MM,10600295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 20MM,10600295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 22MM,10600296,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 22MM,10600296,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 24MM,10600297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 24MM,10600297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 30MM,10600298,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 30MM,10600298,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 36MM,10600299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,705.00,211.50,273.54,599.25,,,,,,,,,,,,,,,,,,,,273.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.25,,,percent of total billed charges,,,317.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 36MM,10600299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,705.00,211.50,299.62,599.25,,,,,,,,,,,,,service not payable,,,,,,,355.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,299.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,528.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,352.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,528.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,599.25,,,percent of total billed charges,,,324.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUM PROX 12H LT 180MM,10600300,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5610.00,1683.00,2176.68,4768.5,,2748.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2356.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2176.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2384.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4207.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2805.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4768.5,,,percent of total billed charges,,,2524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUM PROX 12H LT 180MM,10600300,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5610.00,1683.00,2356.20,4768.5,,2748.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2356.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2829.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2384.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4207.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2805.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4207.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4768.5,,,percent of total billed charges,,,2580.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM VESUVIUS 30CC,10600301,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,10484.00,3145.20,4067.79,8911.40,,5137.16,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4403.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4067.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4455.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7863.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5242.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8911.40,,,percent of total billed charges,,,4717.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE DBM VESUVIUS 30CC,10600301,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,10484.00,3145.20,4403.28,8911.40,,5137.16,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4403.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5288.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4455.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7863.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5242.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7863.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8911.40,,,percent of total billed charges,,,4822.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE DBM VESUVIUS 30CC,10600301,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,10484.00,3145.20,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUMP PENILE 18CMX12MM,10600302,CDM,0278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,31433.00,9429.90,12196.00,26718.05,,15402.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13201.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12196.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13359.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,23574.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15716.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26718.05,,,percent of total billed charges,,,14144.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PUMP PENILE 18CMX12MM,10600302,CDM,0278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,31433.00,9429.90,13201.86,26718.05,,15402.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13201.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,15854.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13359.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,23574.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15716.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,23574.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26718.05,,,percent of total billed charges,,,14459.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LAPBAND GASTRIC STANDARD,10600305,CDM,0278,RC,S2083,HCPCS,,,,,,inpatient,facility,,,13097.00,3929.10,5081.64,11132.45,,6417.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5500.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5081.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5566.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9822.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6548.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11132.45,,,percent of total billed charges,,,5893.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LAPBAND GASTRIC STANDARD,10600305,CDM,0278,RC,S2083,HCPCS,,,,,,outpatient,facility,,,13097.00,3929.10,5500.74,11132.45,,6417.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5500.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6606.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,6548.5,,,fee schedule,,,,,,,,,,,,,,service not payable,6548.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,5566.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9822.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6548.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9822.75,,,percent of total billed charges,,,,,,,,,5893.65,,,fee schedule,,,,,,,,,11132.45,,,percent of total billed charges,,,6024.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,6548.5,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CANN BONE 4.0X48MM,10600306,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CANN BONE 4.0X48MM,10600306,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX NON-LCKG 2.4X12MM,10600307,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX NON-LCKG 2.4X12MM,10600307,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX NON-LCKG 2.4X16MM,10600308,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX NON-LCKG 2.4X16MM,10600308,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HOOK VOLAR 6H,10600309,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3912.00,1173.60,1517.86,3325.20,,,,,,,,,,,,,,,,,,,,1517.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3325.20,,,percent of total billed charges,,,1760.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HOOK VOLAR 6H,10600309,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3912.00,1173.60,1662.60,3325.20,,,,,,,,,,,,,service not payable,,,,,,,1973.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1662.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2934.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1956.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2934.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3325.20,,,percent of total billed charges,,,1799.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NR CORTEX VA TI 2.4X12MM,10600310,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NR CORTEX VA TI 2.4X12MM,10600310,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PS X3 SZ 4 11MM,10601675,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PS X3 SZ 4 11MM,10601675,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH PLATE 0.6MM SM 50X50MM,10601676,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3698.00,1109.40,1434.82,3143.30,,,,,,,,,,,,,,,,,,,,1434.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1571.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1849.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3143.30,,,percent of total billed charges,,,1664.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH PLATE 0.6MM SM 50X50MM,10601676,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3698.00,1109.40,1571.65,3143.30,,,,,,,,,,,,,service not payable,,,,,,,1865.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1571.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2773.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1849.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2773.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3143.30,,,percent of total billed charges,,,1701.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ24,10601678,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ24,10601678,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ26,10601679,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ26,10601679,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ28,10601680,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ28,10601680,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ30,10601681,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ30,10601681,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ32,10601682,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ32,10601682,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ34,10601683,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ34,10601683,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ36,10601684,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ36,10601684,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ38,10601685,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ38,10601685,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ40,10601687,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ40,10601687,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANNULOPLASY RING W/HOLDER SZ42,10601688,CDM,0278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,7687.00,2306.10,2982.56,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2982.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6533.95,,,percent of total billed charges,,,3459.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANNULOPLASY RING W/HOLDER SZ42,10601688,CDM,0278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,7687.00,2306.10,3228.54,6533.95,,3766.63,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3228.54,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3877.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3266.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5765.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3843.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5765.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6533.95,,,percent of total billed charges,,,3536.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BASE T LOCKING 2H6H 2MM,10601692,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3314.00,994.20,1285.83,2816.90,,,,,,,,,,,,,,,,,,,,1285.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2485.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1657.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2816.90,,,percent of total billed charges,,,1491.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BASE T LOCKING 2H6H 2MM,10601692,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3314.00,994.20,1408.45,2816.90,,,,,,,,,,,,,service not payable,,,,,,,1671.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1408.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2485.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1657.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2485.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2816.90,,,percent of total billed charges,,,1524.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX ST STRDRV 2.0X10MM,10601693,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,372.00,111.60,144.34,316.20,,,,,,,,,,,,,,,,,,,,144.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.20,,,percent of total billed charges,,,167.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX ST STRDRV 2.0X10MM,10601693,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,372.00,111.60,158.10,316.20,,,,,,,,,,,,,service not payable,,,,,,,187.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,158.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,279.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,186.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,279.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,316.20,,,percent of total billed charges,,,171.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK VAR ANG ST 2X10MM,10601694,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,968.00,290.40,375.58,822.80,,,,,,,,,,,,,,,,,,,,375.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,411.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,726.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.80,,,percent of total billed charges,,,435.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK VAR ANG ST 2X10MM,10601694,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,968.00,290.40,411.40,822.80,,,,,,,,,,,,,service not payable,,,,,,,488.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,411.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,726.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,484.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,726.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,822.80,,,percent of total billed charges,,,445.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCK VAR ANG ST 2X12MM,10601695,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,968.00,290.40,375.58,822.80,,,,,,,,,,,,,,,,,,,,375.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,411.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,726.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.80,,,percent of total billed charges,,,435.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCK VAR ANG ST 2X12MM,10601695,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,968.00,290.40,411.40,822.80,,,,,,,,,,,,,service not payable,,,,,,,488.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,411.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,726.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,484.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,726.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,822.80,,,percent of total billed charges,,,445.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 3DMAX MID RT LG 4X6IN,10601697,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1247.00,374.10,483.84,1059.95,,,,,,,,,,,,,,,,,,,,483.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,935.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,623.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.95,,,percent of total billed charges,,,561.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 3DMAX MID RT LG 4X6IN,10601697,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1247.00,374.10,529.98,1059.95,,,,,,,,,,,,,service not payable,,,,,,,628.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,529.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,935.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,623.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,935.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1059.95,,,percent of total billed charges,,,573.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 3DMAX MID LT LG 4X6IN,10601698,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1247.00,374.10,483.84,1059.95,,,,,,,,,,,,,,,,,,,,483.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,935.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,623.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1059.95,,,percent of total billed charges,,,561.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 3DMAX MID LT LG 4X6IN,10601698,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1247.00,374.10,529.98,1059.95,,,,,,,,,,,,,service not payable,,,,,,,628.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,529.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,935.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,623.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,935.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1059.95,,,percent of total billed charges,,,573.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 3DMAX MID RT XLG 5X7IN,10601699,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1376.00,412.80,533.89,1169.60,,,,,,,,,,,,,,,,,,,,533.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,584.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1032.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,688.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1169.60,,,percent of total billed charges,,,619.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 3DMAX MID RT XLG 5X7IN,10601699,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1376.00,412.80,584.80,1169.60,,,,,,,,,,,,,service not payable,,,,,,,694.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,584.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1032.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,688.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1032.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1169.60,,,percent of total billed charges,,,632.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 3DMAX MID LT XLG 5X7IN,10601700,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1376.00,412.80,533.89,1169.60,,,,,,,,,,,,,,,,,,,,533.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,584.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1032.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,688.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1169.60,,,percent of total billed charges,,,619.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 3DMAX MID LT XLG 5X7IN,10601700,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1376.00,412.80,584.80,1169.60,,,,,,,,,,,,,service not payable,,,,,,,694.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,584.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1032.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,688.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1032.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1169.60,,,percent of total billed charges,,,632.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHAMBER 13MM 7.0,10601701,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHAMBER 13MM 7.0,10601701,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH FLAT 6X6IN,10601702,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,285.00,85.50,110.58,242.25,,,,,,,,,,,,,,,,,,,,110.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH FLAT 6X6IN,10601702,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,285.00,85.50,121.12,242.25,,,,,,,,,,,,,service not payable,,,,,,,143.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,121.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,213.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,142.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,213.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,242.25,,,percent of total billed charges,,,131.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Angioplasty FEM/POP Revas W/TLA,10601933,CDM,0481,RC,37224,CPT,,,,,,outpatient,facility,,,13004.00,3901.20,5463.36,12795.0,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,6559.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,9753.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,9753.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11053.4,,,percent of total billed charges,,,5981.84,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Angioplasty FEM/POP Revas W/TLA,10601933,CDM,0481,RC,37224,CPT,05192,APC,,,,outpatient,facility,,,13004.00,3901.20,5244.41,12557.62,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,11501.89,,,fee schedule,,,5244.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5576.92,,,fee schedule,,,12557.62,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,11335.20,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,5244.41,,,fee schedule,,,5576.92,,,fee schedule,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,5244.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5576.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,,,,,,,5467.57,,,fee schedule,,,,,,,,,5522.02,,,fee schedule,,,,,,,,
Angioplasty FEM/POP Revas W/TLA,10601933,CDM,0481,RC,37224,CPT,79,EAPG,,,,outpatient,facility,,,13004.00,3901.20,6925.40,15648.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15648.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,13301.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8988.34,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6925.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,7617.94,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH ANGIOGRAPHY SIM1 TIP 5F 100CM X_G04922 X_COOK,10601982,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,145.00,43.50,61.63,123.25,,89.61,,,percent of total billed charges,,,,,,,,service not payable,70.76,,,percent of total billed charges,,,73.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,61.63,,,percent of total billed charges,,,,,,,,,108.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,72.5,,,percent of total billed charges,,,,,,,,service not payable,108.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,123.25,,,percent of total billed charges,,,66.70,,,percent of total billed charges,,,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,94.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS FLEX LT SZ G,10601984,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS FLEX LT SZ G,10601984,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOC AKREOS AO 21.5,10601989,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOC AKREOS AO 21.5,10601989,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM ECC SZ 40X18MM,10601990,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6556.00,1966.80,2543.73,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2543.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5572.60,,,percent of total billed charges,,,2950.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM ECC SZ 40X18MM,10601990,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6556.00,1966.80,2753.52,5572.60,,3212.44,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2753.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3306.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2786.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4917.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3278.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4917.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5572.60,,,percent of total billed charges,,,3015.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET REVISION SZ 56MM,10601991,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10786.00,3235.80,4184.97,9168.10,,5285.14,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4530.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4184.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8089.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9168.10,,,percent of total billed charges,,,4853.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET REVISION SZ 56MM,10601991,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10786.00,3235.80,4530.12,9168.10,,5285.14,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4530.12,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5440.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4584.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8089.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5393.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8089.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9168.10,,,percent of total billed charges,,,4961.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HGP 2 TI ST 6.5X15,10601992,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,716.00,214.80,277.81,608.60,,,,,,,,,,,,,,,,,,,,277.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,322.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HGP 2 TI ST 6.5X15,10601992,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,716.00,214.80,304.30,608.60,,,,,,,,,,,,,service not payable,,,,,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,537.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN HGP 2 TI ST 6.5X35,10601993,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,716.00,214.80,277.81,608.60,,,,,,,,,,,,,,,,,,,,277.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,322.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN HGP 2 TI ST 6.5X35,10601993,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,716.00,214.80,304.30,608.60,,,,,,,,,,,,,service not payable,,,,,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,537.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE RT SH FLNGE 56/58/60SH/48,10601994,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10228.00,3068.40,3968.46,8693.80,,5011.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4295.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3968.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4346.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7671.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8693.80,,,percent of total billed charges,,,4602.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE RT SH FLNGE 56/58/60SH/48,10601994,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10228.00,3068.40,4295.76,8693.80,,5011.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4295.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5159.0,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4346.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7671.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7671.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8693.80,,,percent of total billed charges,,,4704.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE PROV RT SH FL SHELL/LINER,10601995,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,1502.00,450.60,582.78,1276.7,,,,,,,,,,,,,,,,,,,,582.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276.7,,,percent of total billed charges,,,675.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE PROV RT SH FL SHELL/LINER,10601995,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,1502.00,450.60,638.35,1276.7,,,,,,,,,,,,,service not payable,,,,,,,757.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,638.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,751.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1126.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1276.7,,,percent of total billed charges,,,690.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE ST 6.5X60MM,10601996,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,716.00,214.80,277.81,608.60,,,,,,,,,,,,,,,,,,,,277.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,322.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE ST 6.5X60MM,10601996,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,716.00,214.80,304.30,608.60,,,,,,,,,,,,,service not payable,,,,,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,537.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEG FT 2.5MMX14MM,10602122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,419.00,125.70,162.57,356.15,,,,,,,,,,,,,,,,,,,,162.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,314.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.15,,,percent of total billed charges,,,188.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEG FT 2.5MMX14MM,10602122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,419.00,125.70,178.07,356.15,,,,,,,,,,,,,service not payable,,,,,,,211.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,314.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,209.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,314.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,356.15,,,percent of total billed charges,,,192.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 19.5,10602124,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 19.5,10602124,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 20.5,10602125,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 20.5,10602125,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 21.0,10602126,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 21.0,10602126,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 21.5,10602127,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 21.5,10602127,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 22.5,10602128,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 22.5,10602128,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE ALLOGRAFT PUROS 2.5,10602129,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2077.00,623.10,805.88,1765.45,,,,,,,,,,,,,,,,,,,,805.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,882.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1765.45,,,percent of total billed charges,,,934.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE ALLOGRAFT PUROS 2.5,10602129,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2077.00,623.10,882.73,1765.45,,,,,,,,,,,,,service not payable,,,,,,,1047.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,882.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1557.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1038.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1557.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1765.45,,,percent of total billed charges,,,955.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 1.6 X 6MM,10602130,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.6 X 6MM,10602130,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 1.6 X 7MM,10602131,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.6 X 7MM,10602131,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORTICAL 1.6 X 10MM,10602132,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORTICAL 1.6 X 10MM,10602132,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CS X3 SZ5 13MM,10602133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CS X3 SZ5 13MM,10602133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP VRS 12/14X28MMX0,10602465,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP VRS 12/14X28MMX0,10602465,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA PKS 5DEG L SZH,10602466,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA PKS 5DEG L SZH,10602466,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE AMNIOGRAFT AMNIOTIC 5X5,10602467,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE AMNIOGRAFT AMNIOTIC 5X5,10602467,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert tunneled CV device w/port age 5 and older,10602806,CDM,0481,RC,36561,CPT,,,,,,outpatient,facility,,,8757.00,2627.10,4028.22,7443.45,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,4417.03,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,6567.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,6567.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7443.45,,,percent of total billed charges,,,4028.22,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert tunneled CV device w/port age 5 and older,10602806,CDM,0481,RC,36561,CPT,05183,APC,,,,outpatient,facility,,,8757.00,2627.10,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Insert tunneled CV device w/port age 5 and older,10602806,CDM,0481,RC,36561,CPT,83,EAPG,,,,outpatient,facility,,,8757.00,2627.10,3082.81,8961.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7617.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3891.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4280.91,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE STRAIGHT 2.0MM 6H,10602821,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE STRAIGHT 2.0MM 6H,10602821,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP CORTICAL 2.0X15MM,10602822,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP CORTICAL 2.0X15MM,10602822,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2.0 X 10MM,10602823,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2.0 X 10MM,10602823,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 16MM 79/83M,10602824,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 16MM 79/83M,10602824,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SENSAR 6.0 -04.0D,10602825,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,956.00,286.80,370.93,812.60,,,,,,,,,,,,,,,,,,,,370.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.60,,,percent of total billed charges,,,430.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SENSAR 6.0 -04.0D,10602825,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,956.00,286.80,406.30,812.60,,,,,,,,,,,,,service not payable,,,,,,,482.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,717.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,812.60,,,percent of total billed charges,,,439.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SENSAR OPT POST CH 04.0D,10602826,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,956.00,286.80,370.93,812.60,,,,,,,,,,,,,,,,,,,,370.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.60,,,percent of total billed charges,,,430.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SENSAR OPT POST CH 04.0D,10602826,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,956.00,286.80,406.30,812.60,,,,,,,,,,,,,service not payable,,,,,,,482.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,406.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,717.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,478.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,717.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,812.60,,,percent of total billed charges,,,439.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SHORT RT 13MMX21.5CM 130D,10602827,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3806.00,1141.80,1476.73,3235.10,,,,,,,,,,,,,,,,,,,,1476.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3235.10,,,percent of total billed charges,,,1712.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SHORT RT 13MMX21.5CM 130D,10602827,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3806.00,1141.80,1617.55,3235.10,,,,,,,,,,,,,service not payable,,,,,,,1919.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3235.10,,,percent of total billed charges,,,1750.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert/Replace Dual  Lead Pulse Generator,10602950,CDM,0481,RC,33213,CPT,,,,,,outpatient,facility,,,15735.00,4720.50,4917.20,18583.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,7936.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,11801.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,11801.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13374.75,,,percent of total billed charges,,,7238.10,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert/Replace Dual  Lead Pulse Generator,10602950,CDM,0481,RC,33213,CPT,05223,APC,,,,outpatient,facility,,,15735.00,4720.50,9626.29,23049.94,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,21112.12,,,fee schedule,,,9626.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",10229.20,,,fee schedule,,,23049.94,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,20806.14,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,9626.29,,,fee schedule,,,10229.20,,,fee schedule,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,9626.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",10229.20,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,,,,,,,10028.63,,,fee schedule,,,,,,,,,10128.58,,,fee schedule,,,,,,,,
Insert/Replace Dual  Lead Pulse Generator,10602950,CDM,0481,RC,33213,CPT,86,EAPG,,,,outpatient,facility,,,15735.00,4720.50,11447.48,18869.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18869.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,16039.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,11447.48,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15143.5,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,16657.85,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CONNECT TRANSV ADJ 33-36 5.5MM,10602966,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECT TRANSV ADJ 33-36 5.5MM,10602966,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECT TRANSV ADJ 36-41 5.5MM,10602967,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECT TRANSV ADJ 36-41 5.5MM,10602967,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONNECT TRANSV ADJ 70-90 5.5MM,10602968,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONNECT TRANSV ADJ 70-90 5.5MM,10602968,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTIAXIAL 7.5X35MM,10602969,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTIAXIAL 7.5X35MM,10602969,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 5.5X40MM,10602970,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 5.5X40MM,10602970,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL VIT 5.5X50MM,10602971,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL VIT 5.5X50MM,10602971,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 5.5X55MM,10602972,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 5.5X55MM,10602972,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 7.5X35MM,10602973,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 7.5X35MM,10602973,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 7.5X40MM,10602974,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 7.5X40MM,10602974,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLYAXIAL 7.5X60MM,10602975,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLYAXIAL 7.5X60MM,10602975,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LEVEL 1 CERV ANT 18MM,10602976,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LEVEL 1 CERV ANT 18MM,10602976,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LEVEL 1 CERV ANT 20MM,10602977,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LEVEL 1 CERV ANT 20MM,10602977,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LEVEL 1 CERV ANT 22MM,10602978,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LEVEL 1 CERV ANT 22MM,10602978,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LEVEL 2 CERV ANT 20MM,10602979,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LEVEL 2 CERV ANT 20MM,10602979,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LEVEL 2 CERV ANT 42MM,10602980,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LEVEL 2 CERV ANT 42MM,10602980,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER ALLOGRAFT PLIF 14MMX3D,10602981,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER ALLOGRAFT PLIF 14MMX3D,10602981,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CURVED TI 5.5X55MM,10602982,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CURVED TI 5.5X55MM,10602982,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CURVED 6D 7.0X27MM,10602983,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CURVED 6D 7.0X27MM,10602983,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CURVED 6D 13X27MM,10602984,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CURVED 6D 13X27MM,10602984,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 7H 20LX10W,10602985,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 7H 20LX10W,10602985,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 8H 20LX10W,10602986,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 8H 20LX10W,10602986,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 9H 20LX10W,10602987,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 9H 20LX10W,10602987,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 10H 20LX10W,10602988,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 10H 20LX10W,10602988,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 11H 20LX10W,10602989,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 11H 20LX10W,10602989,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 12H 20LX10W,10602990,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 12H 20LX10W,10602990,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 13H 20LX11W,10602991,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 13H 20LX11W,10602991,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 7H 25LX10W,10602992,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 7H 25LX10W,10602992,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 8H 25LX10W,10602993,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 8H 25LX10W,10602993,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 9H 25LX10W,10602994,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 9H 25LX10W,10602994,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 10H 25LX10W,10602995,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 10H 25LX10W,10602995,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 13H 25LX10W,10602996,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 13H 25LX10W,10602996,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER CERV STR 8D 14H 25LX10W,10602997,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER CERV STR 8D 14H 25LX10W,10602997,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN MAXAN DISTRACTION 12MM,10602998,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN MAXAN DISTRACTION 12MM,10602998,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SELFDRILL FIXED 4.0X10MM,10602999,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SELFDRILL FIXED 4.0X10MM,10602999,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2 CASPAR PIN 12MM,10603000,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2 CASPAR PIN 12MM,10603000,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC MOBI-C H6 CERV 13X15MM,10603001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC MOBI-C H6 CERV 13X15MM,10603001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC MOBI-C H5 CERV 13X15MM,10603002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC MOBI-C H5 CERV 13X15MM,10603002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC MOBI-C H5 CERV 17X17MM,10603003,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC MOBI-C H5 CERV 17X17MM,10603003,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DISC MOBI-C H6 CERV 17X17MM,10603004,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISC MOBI-C H6 CERV 17X17MM,10603004,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATCH MYRINGO XL,10603013,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATCH MYRINGO XL,10603013,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATCH STEM XL,10603014,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATCH STEM XL,10603014,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PS INTLK 72.5MM LT,10603015,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PS INTLK 72.5MM LT,10603015,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR HW G7 40MM F,10603016,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR HW G7 40MM F,10603016,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP 40MM  9MM,10603017,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP 40MM  9MM,10603017,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CDM RT 10X38MM LEFT,10603018,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4397.00,1319.10,1706.04,3737.45,,,,,,,,,,,,,,,,,,,,1706.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1868.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3297.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2198.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3737.45,,,percent of total billed charges,,,1978.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CDM RT 10X38MM LEFT,10603018,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4397.00,1319.10,1868.72,3737.45,,,,,,,,,,,,,service not payable,,,,,,,2217.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1868.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3297.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2198.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3297.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3737.45,,,percent of total billed charges,,,2022.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/3 4H 49MM,10603021,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,384.00,115.20,148.99,326.40,,,,,,,,,,,,,,,,,,,,148.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,172.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/3 4H 49MM,10603021,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,,,,,,,,,,,,service not payable,,,,,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV LVL 1,10603022,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3170.00,951.00,1229.96,2694.5,,,,,,,,,,,,,,,,,,,,1229.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2694.5,,,percent of total billed charges,,,1426.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV LVL 1,10603022,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3170.00,951.00,1347.25,2694.5,,,,,,,,,,,,,service not payable,,,,,,,1598.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1347.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2377.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1585.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2377.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2694.5,,,percent of total billed charges,,,1458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE ATTUNE REV PC TIB 45MM,10603024,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12994.00,3898.20,5041.67,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5041.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11044.9,,,percent of total billed charges,,,5847.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE ATTUNE REV PC TIB 45MM,10603024,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12994.00,3898.20,5457.48,11044.9,,6367.06,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5457.48,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6554.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5522.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9745.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6497.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9745.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11044.9,,,percent of total billed charges,,,5977.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT REV PLATFORM SZ7 16MM,10603025,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT REV PLATFORM SZ7 16MM,10603025,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Injection extremity venography,10603406,CDM,0481,RC,36005,CPT,,,,,,outpatient,facility,,,617.00,185.10,283.82,2912.34,,617.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,311.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1106.0,,,case rate,,,,,,,,,462.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,service not payable,462.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,524.45,,,percent of total billed charges,,,283.82,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,service not payable,,,,,,,1562.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Injection extremity venography,10603406,CDM,0481,RC,36005,CPT,423,EAPG,,,,outpatient,facility,,,617.00,185.10,617.0,1945.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1945.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1653.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,617.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,617.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1339.82,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1473.8,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LINER CUP E1 UHMWPE 28X38MM,10603460,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER CUP E1 UHMWPE 28X38MM,10603460,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETABULAR G7 38MM,10603461,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5665.00,1699.50,2198.02,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2198.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4815.25,,,percent of total billed charges,,,2549.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETABULAR G7 38MM,10603461,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5665.00,1699.50,2379.30,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2857.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4815.25,,,percent of total billed charges,,,2605.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X7MM,10603462,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X7MM,10603462,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT MINI HEX 2.0X20MM,10603463,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT MINI HEX 2.0X20MM,10603463,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT MINI HEX 2.0X22MM,10603464,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT MINI HEX 2.0X22MM,10603464,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE 3.0X508MM,10603623,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,885.00,265.50,343.38,752.25,,,,,,,,,,,,,,,,,,,,343.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,376.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,663.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.25,,,percent of total billed charges,,,398.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE 3.0X508MM,10603623,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,885.00,265.50,376.12,752.25,,,,,,,,,,,,,service not payable,,,,,,,446.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,376.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,663.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,663.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,752.25,,,percent of total billed charges,,,407.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PSN VE REV CCL RT 18MM SZ7-9GH,10603624,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PSN VE REV CCL RT 18MM SZ7-9GH,10603624,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV OFFSET 6MM 14X135,10603625,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV OFFSET 6MM 14X135,10603625,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PSN REV FIXED KEEL CMT SZ G RT,10603626,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PSN REV FIXED KEEL CMT SZ G RT,10603626,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE PSN FEM POST SZ 9 10MM,10603627,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE PSN FEM POST SZ 9 10MM,10603627,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV STR SPLINE 16X135,10603628,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5655.00,1696.50,2194.14,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2194.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4806.75,,,percent of total billed charges,,,2544.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV STR SPLINE 16X135,10603628,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5655.00,1696.50,2375.10,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2852.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4806.75,,,percent of total billed charges,,,2601.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT MINI CRUCI 2.0X24MM,10603629,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT MINI CRUCI 2.0X24MM,10603629,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-Sm intestine enteroscopy beyond 2nd part of d,10603768,CDM,0750,RC,44372,CPT,,,,,,outpatient,facility,,,5133.00,1539.90,1972.0,4778.89,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,2589.09,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,3849.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,3849.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4363.05,,,percent of total billed charges,,,2361.18,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
END-Sm intestine enteroscopy beyond 2nd part of d,10603768,CDM,0750,RC,44372,CPT,05302,APC,,,,outpatient,facility,,,5133.00,1539.90,1744.90,4178.13,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,3826.87,,,fee schedule,,,1744.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1855.53,,,fee schedule,,,4178.13,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,3771.41,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,1744.90,,,fee schedule,,,1855.53,,,fee schedule,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,1744.90,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1855.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,,,,,,,1819.15,,,fee schedule,,,,,,,,,1837.27,,,fee schedule,,,,,,,,
END-Sm intestine enteroscopy beyond 2nd part of d,10603768,CDM,0750,RC,44372,CPT,134,EAPG,,,,outpatient,facility,,,5133.00,1539.90,1403.14,4560.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4560.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3876.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1403.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1403.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1403.14,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1917.04,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2108.74,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WASHER SCREW MINI 2X4.5X0.5MM,10603797,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SCREW MINI 2X4.5X0.5MM,10603797,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH 7FR 23CM 21GX4CM ADV SC,10603798,CDM,0272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,274.00,82.20,116.45,232.90,,169.33,,,percent of total billed charges,,,,,,,,service not payable,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,178.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LOCKING T SHAPE 2.5MM,10603799,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2104.00,631.20,816.35,1788.40,,,,,,,,,,,,,,,,,,,,816.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.40,,,percent of total billed charges,,,946.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LOCKING T SHAPE 2.5MM,10603799,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2104.00,631.20,894.20,1788.40,,,,,,,,,,,,,service not payable,,,,,,,1061.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,894.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1578.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1052.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1578.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1788.40,,,percent of total billed charges,,,967.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER SCREW THREADED 2.5MM,10603800,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SCREW THREADED 2.5MM,10603800,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NLK FT 2.5X13MM,10603801,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,437.00,131.10,169.56,371.45,,,,,,,,,,,,,,,,,,,,169.56,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.45,,,percent of total billed charges,,,196.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NLK FT 2.5X13MM,10603801,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,437.00,131.10,185.72,371.45,,,,,,,,,,,,,service not payable,,,,,,,220.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,185.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,327.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,218.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,327.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,371.45,,,percent of total billed charges,,,201.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAV SUP RT 10H 110MM,10603802,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAV SUP RT 10H 110MM,10603802,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 LP 3.5X14MM,10603803,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 LP 3.5X14MM,10603803,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 LP 3.5X16MM,10603804,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 LP 3.5X16MM,10603804,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 MD 3.5X12MM,10603806,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,961.00,288.30,372.87,816.85,,,,,,,,,,,,,,,,,,,,372.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,408.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,720.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,480.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.85,,,percent of total billed charges,,,432.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 MD 3.5X12MM,10603806,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,961.00,288.30,408.43,816.85,,,,,,,,,,,,,service not payable,,,,,,,484.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,408.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,720.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,480.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,720.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,816.85,,,percent of total billed charges,,,442.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE FIXATION BTB TIGHTROPE,10603807,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2432.00,729.60,943.62,2067.20,,,,,,,,,,,,,,,,,,,,943.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1033.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1824.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1216.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2067.20,,,percent of total billed charges,,,1094.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE FIXATION BTB TIGHTROPE,10603807,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2432.00,729.60,1033.60,2067.20,,,,,,,,,,,,,service not payable,,,,,,,1226.7,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1033.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1824.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1216.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1824.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2067.20,,,percent of total billed charges,,,1118.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM MODULAR STD 36MM,10603808,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4786.00,1435.80,1856.97,4068.10,,,,,,,,,,,,,,,,,,,,1856.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2034.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3589.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2393.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4068.10,,,percent of total billed charges,,,2153.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM MODULAR STD 36MM,10603808,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4786.00,1435.80,2034.05,4068.10,,,,,,,,,,,,,service not payable,,,,,,,2414.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2034.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3589.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2393.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3589.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4068.10,,,percent of total billed charges,,,2201.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACET G7 E1 SZ F 36MM,10603809,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10557.00,3167.10,4096.12,8973.45,,5172.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4433.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4096.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4486.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7917.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5278.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8973.45,,,percent of total billed charges,,,4750.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACET G7 E1 SZ F 36MM,10603809,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10557.00,3167.10,4433.94,8973.45,,5172.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4433.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5324.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4486.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7917.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5278.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7917.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8973.45,,,percent of total billed charges,,,4856.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT SZ 3-5 CD 18MM RIGHT,10603810,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT SZ 3-5 CD 18MM RIGHT,10603810,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB PERSONA REVIS RT SZ D,10603811,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB PERSONA REVIS RT SZ D,10603811,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM TIBIAL STR L 135MM 12MM,10603812,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5655.00,1696.50,2194.14,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2194.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4806.75,,,percent of total billed charges,,,2544.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM TIBIAL STR L 135MM 12MM,10603812,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5655.00,1696.50,2375.10,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2852.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4806.75,,,percent of total billed charges,,,2601.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT STR SPLINE 135X14MM,10603813,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5655.00,1696.50,2194.14,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2194.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4806.75,,,percent of total billed charges,,,2544.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT STR SPLINE 135X14MM,10603813,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5655.00,1696.50,2375.10,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2852.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4806.75,,,percent of total billed charges,,,2601.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CCR REVIS RT SZ 5,10603814,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23357.00,7007.10,9062.52,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9062.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19853.45,,,percent of total billed charges,,,10510.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CCR REVIS RT SZ 5,10603814,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23357.00,7007.10,9809.94,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11781.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19853.45,,,percent of total billed charges,,,10744.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Midline Insertion >age 3,10604572,CDM,0761,RC,36410,CPT,,,,,,outpatient,facility,,,40.00,12.00,17.0,134.0,,24.72,,,percent of total billed charges,,,,,,,,service not payable,19.52,,,percent of total billed charges,,,20.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17.0,,,percent of total billed charges,,,,,,,,,30.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20.0,,,percent of total billed charges,,,,,,,,service not payable,30.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34.0,,,percent of total billed charges,,,18.40,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,service not payable,,,,,,,118.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Midline Insertion >age 3,10604572,CDM,0761,RC,36410,CPT,494,EAPG,,,,outpatient,facility,,,40.00,12.00,40.0,553.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,470.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,40.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,40.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,354.64,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,390.10,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW NON LCKG2.7X18MM,10604750,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,320.00,96.00,124.16,272.0,,,,,,,,,,,,,,,,,,,,124.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.0,,,percent of total billed charges,,,144.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NON LCKG2.7X18MM,10604750,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,320.00,96.00,136.0,272.0,,,,,,,,,,,,,service not payable,,,,,,,161.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,240.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.0,,,percent of total billed charges,,,147.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X18MM,10604751,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,763.00,228.90,296.04,648.55,,,,,,,,,,,,,,,,,,,,296.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,572.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,381.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.55,,,percent of total billed charges,,,343.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X18MM,10604751,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,763.00,228.90,324.27,648.55,,,,,,,,,,,,,service not payable,,,,,,,384.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,324.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,572.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,381.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,572.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,648.55,,,percent of total billed charges,,,350.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST LAT LCK 7H RIGHT,10604752,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3454.00,1036.20,1340.15,2935.90,,,,,,,,,,,,,,,,,,,,1340.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1467.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2590.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1727.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2935.90,,,percent of total billed charges,,,1554.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST LAT LCK 7H RIGHT,10604752,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3454.00,1036.20,1467.95,2935.90,,,,,,,,,,,,,service not payable,,,,,,,1742.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1467.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2590.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1727.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2590.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2935.90,,,percent of total billed charges,,,1588.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DIST MED HUM LCK 5H RT,10604753,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3520.00,1056.00,1365.76,2992.0,,,,,,,,,,,,,,,,,,,,1365.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2640.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1760.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2992.0,,,percent of total billed charges,,,1584.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DIST MED HUM LCK 5H RT,10604753,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3520.00,1056.00,1496.0,2992.0,,,,,,,,,,,,,service not payable,,,,,,,1775.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1496.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2640.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1760.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2640.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2992.0,,,percent of total billed charges,,,1619.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 2.7MM 36MM,10604754,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 2.7MM 36MM,10604754,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 2.7MM 44MM,10604755,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 2.7MM 44MM,10604755,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 2.7MM 60MM,10604756,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 2.7MM 60MM,10604756,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5MM W/2.7 HD 20MM,10604757,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5MM W/2.7 HD 20MM,10604757,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTP HEX 2.7X55MM,10604758,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTP HEX 2.7X55MM,10604758,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTP HEX 2.7X50MM,10604759,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTP HEX 2.7X50MM,10604759,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIBIAL REMEDY LG,10604760,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL REMEDY LG,10604760,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT REMEDY FEMORAL MD,10604761,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT REMEDY FEMORAL MD,10604761,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 37X90MM,10604762,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,38399.00,11519.70,14898.81,32639.15,,18815.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16127.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14898.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16319.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28799.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19199.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32639.15,,,percent of total billed charges,,,17279.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 37X90MM,10604762,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,38399.00,11519.70,16127.58,32639.15,,18815.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16127.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19368.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16319.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28799.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19199.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28799.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32639.15,,,percent of total billed charges,,,17663.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT GRAFT THORACIC 34X90MM,10604763,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,38399.00,11519.70,14898.81,32639.15,,18815.51,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16127.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14898.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16319.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28799.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19199.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32639.15,,,percent of total billed charges,,,17279.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT GRAFT THORACIC 34X90MM,10604763,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,38399.00,11519.70,16127.58,32639.15,,18815.51,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16127.58,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19368.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16319.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28799.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19199.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28799.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32639.15,,,percent of total billed charges,,,17663.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 10MMX38CM 130DEG,10604764,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 10MMX38CM 130DEG,10604764,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTICAL 5X52.5MM,10604765,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,864.00,259.20,335.23,734.40,,,,,,,,,,,,,,,,,,,,335.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,648.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734.40,,,percent of total billed charges,,,388.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTICAL 5X52.5MM,10604765,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,864.00,259.20,367.20,734.40,,,,,,,,,,,,,service not payable,,,,,,,435.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,648.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,648.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,734.40,,,percent of total billed charges,,,397.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUFF OCCLUSIVE 3.5CM 800,10604766,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21652.00,6495.60,8400.98,18404.20,,10609.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9093.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8400.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9202.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16239.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10826.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18404.20,,,percent of total billed charges,,,9743.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUFF OCCLUSIVE 3.5CM 800,10604766,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21652.00,6495.60,9093.84,18404.20,,10609.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9093.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10921.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9202.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16239.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10826.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16239.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18404.20,,,percent of total billed charges,,,9959.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC PROX 38X167,10604767,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,38126.00,11437.80,14792.89,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14792.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32407.10,,,percent of total billed charges,,,17156.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC PROX 38X167,10604767,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,38126.00,11437.80,16012.92,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19230.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32407.10,,,percent of total billed charges,,,17537.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC PROX 36X161MM,10604768,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,38126.00,11437.80,14792.89,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14792.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32407.10,,,percent of total billed charges,,,17156.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC PROX 36X161MM,10604768,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,38126.00,11437.80,16012.92,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19230.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32407.10,,,percent of total billed charges,,,17537.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC PROX 36X209MM,10604769,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,38126.00,11437.80,14792.89,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14792.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32407.10,,,percent of total billed charges,,,17156.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC PROX 36X209MM,10604769,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,38126.00,11437.80,16012.92,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19230.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32407.10,,,percent of total billed charges,,,17537.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE POLYAXIAL 10X3.5M,10604770,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2350.00,705.00,911.80,1997.5,,,,,,,,,,,,,,,,,,,,911.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1997.5,,,percent of total billed charges,,,1057.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE POLYAXIAL 10X3.5M,10604770,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2350.00,705.00,998.75,1997.5,,,,,,,,,,,,,service not payable,,,,,,,1185.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,998.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1762.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1175.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1762.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1997.5,,,percent of total billed charges,,,1081.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING FIX ART SURF PSN RT 14,10604775,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING FIX ART SURF PSN RT 14,10604775,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMUR PSN RT SZ9,10604776,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24013.00,7203.90,9317.04,20411.05,,11766.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10085.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9317.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10205.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18009.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12006.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20411.05,,,percent of total billed charges,,,10805.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMUR PSN RT SZ9,10604776,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24013.00,7203.90,10085.46,20411.05,,11766.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10085.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12112.16,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10205.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18009.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12006.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18009.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20411.05,,,percent of total billed charges,,,11045.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV 3MM 16X135MM,10604777,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV 3MM 16X135MM,10604777,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FIXED PSN RT SZE,10604778,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FIXED PSN RT SZE,10604778,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE TIB RT MED,10604779,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16801.00,5040.30,6518.79,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6518.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14280.85,,,percent of total billed charges,,,7560.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE TIB RT MED,10604779,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16801.00,5040.30,7056.42,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8474.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14280.85,,,percent of total billed charges,,,7728.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT PSN ST 12X175MM,10604780,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5278.00,1583.40,2047.86,4486.30,,2586.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2216.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2047.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2243.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3958.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2639.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4486.30,,,percent of total billed charges,,,2375.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT PSN ST 12X175MM,10604780,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5278.00,1583.40,2216.76,4486.30,,2586.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2216.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2662.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2243.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3958.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2639.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3958.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4486.30,,,percent of total billed charges,,,2427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 51X28MM,10604781,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 51X28MM,10604781,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 17X154MM,10604782,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 17X154MM,10604782,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MAGSEED SM18 1 07 SEED 18G 7CM,10604783,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,17555.00,5266.50,6811.34,14921.75,,8601.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7373.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6811.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7460.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13166.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8777.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14921.75,,,percent of total billed charges,,,7899.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGSEED SM18 1 07 SEED 18G 7CM,10604783,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,17555.00,5266.50,7373.10,14921.75,,8601.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7373.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8854.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7460.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13166.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8777.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13166.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14921.75,,,percent of total billed charges,,,8075.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM LAB MAGSEED MAG MRK,10604784,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,17555.00,5266.50,6811.34,14921.75,,8601.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7373.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6811.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7460.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13166.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8777.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14921.75,,,percent of total billed charges,,,7899.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM LAB MAGSEED MAG MRK,10604784,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,17555.00,5266.50,7373.10,14921.75,,8601.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7373.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8854.74,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7460.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13166.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8777.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13166.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14921.75,,,percent of total billed charges,,,8075.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL1 MAXDRIVE 2X8MM,10604785,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1022.00,306.60,396.54,868.70,,,,,,,,,,,,,,,,,,,,396.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,766.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,511.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.70,,,percent of total billed charges,,,459.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL1 MAXDRIVE 2X8MM,10604785,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1022.00,306.60,434.35,868.70,,,,,,,,,,,,,service not payable,,,,,,,515.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,434.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,766.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,511.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,766.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,868.70,,,percent of total billed charges,,,470.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL1 MAXDRIVE 2X6MM,10604786,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1022.00,306.60,396.54,868.70,,,,,,,,,,,,,,,,,,,,396.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,766.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,511.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.70,,,percent of total billed charges,,,459.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL1 MAXDRIVE 2X6MM,10604786,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1022.00,306.60,434.35,868.70,,,,,,,,,,,,,service not payable,,,,,,,515.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,434.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,766.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,511.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,766.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,868.70,,,percent of total billed charges,,,470.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL1 MAXDRIVE 2X6MM (5),10604787,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4017.00,1205.10,1558.60,3414.45,,,,,,,,,,,,,,,,,,,,1558.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3414.45,,,percent of total billed charges,,,1807.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL1 MAXDRIVE 2X6MM (5),10604787,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4017.00,1205.10,1707.22,3414.45,,,,,,,,,,,,,service not payable,,,,,,,2026.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3414.45,,,percent of total billed charges,,,1847.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL1 2MM 7H 110MM,10604788,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2377.00,713.10,922.28,2020.45,,,,,,,,,,,,,,,,,,,,922.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1010.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1188.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,,1069.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL1 2MM 7H 110MM,10604788,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2377.00,713.10,1010.22,2020.45,,,,,,,,,,,,,service not payable,,,,,,,1198.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1010.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1782.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1188.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1782.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,,1093.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL1 MAXDRIVE 2X8MM (5),10604789,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4017.00,1205.10,1558.60,3414.45,,,,,,,,,,,,,,,,,,,,1558.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3414.45,,,percent of total billed charges,,,1807.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL1 MAXDRIVE 2X8MM (5),10604789,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4017.00,1205.10,1707.22,3414.45,,,,,,,,,,,,,service not payable,,,,,,,2026.17,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1707.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3012.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3012.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3414.45,,,percent of total billed charges,,,1847.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM 11.5MMX36CM 130DEG,10604790,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM 11.5MMX36CM 130DEG,10604790,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL SHORT RT 11.5MMX21.5MM,10604791,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3806.00,1141.80,1476.73,3235.10,,,,,,,,,,,,,,,,,,,,1476.73,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3235.10,,,percent of total billed charges,,,1712.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL SHORT RT 11.5MMX21.5MM,10604791,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3806.00,1141.80,1617.55,3235.10,,,,,,,,,,,,,service not payable,,,,,,,1919.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1617.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2854.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1903.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2854.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3235.10,,,percent of total billed charges,,,1750.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VPC 4X22MM,10604792,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VPC 4X22MM,10604792,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K-WIRE 1.4X127MM,10604793,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,148.00,44.40,57.42,125.8,,,,,,,,,,,,,,,,,,,,57.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,66.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K-WIRE 1.4X127MM,10604793,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,,,,,,,,,,,,service not payable,,,,,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VPC 3.4X20MM,10604797,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VPC 3.4X20MM,10604797,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VPC 3.4MM X 34MM,10604798,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VPC 3.4MM X 34MM,10604798,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
K-WIRE 1.1 X 105MM,10604800,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,148.00,44.40,57.42,125.8,,,,,,,,,,,,,,,,,,,,57.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.8,,,percent of total billed charges,,,66.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
K-WIRE 1.1 X 105MM,10604800,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,148.00,44.40,62.90,125.8,,,,,,,,,,,,,service not payable,,,,,,,74.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,111.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,74.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,111.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,125.8,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB BEARING LT SZ G,10604897,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB BEARING LT SZ G,10604897,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR SIZE 10 LEFT,10604898,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR SIZE 10 LEFT,10604898,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SUR PSN 12MM LT,10604899,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SUR PSN 12MM LT,10604899,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL 9.3MM X 34CM,10604900,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4161.00,1248.30,1614.47,3536.85,,,,,,,,,,,,,,,,,,,,1614.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1768.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3120.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2080.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3536.85,,,percent of total billed charges,,,1872.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL 9.3MM X 34CM,10604900,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4161.00,1248.30,1768.42,3536.85,,,,,,,,,,,,,service not payable,,,,,,,2098.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1768.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3120.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2080.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3120.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3536.85,,,percent of total billed charges,,,1914.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PFL-Pulmonary Lab Exercise Challenge,10605265,CDM,0482,RC,93017,CPT,,,,,,outpatient,facility,,,1000.00,300.00,83.93,982.0,,112.48,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,83.93,,,fee schedule,,,504.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.0,,,percent of total billed charges,,,,,,,,,750.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,500.0,,,percent of total billed charges,,,,,,,,,750.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,850.0,,,percent of total billed charges,,,460.0,,,percent of total billed charges,,,,,,,,,982.0,,,per diem,,,,,,,,,,,,,,,864.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
PFL-Pulmonary Lab Exercise Challenge,10605265,CDM,0482,RC,93017,CPT,05722,APC,,,,outpatient,facility,,,1000.00,300.00,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
PFL-Pulmonary Lab Exercise Challenge,10605265,CDM,0482,RC,93017,CPT,80,EAPG,,,,outpatient,facility,,,1000.00,300.00,241.11,741.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,741.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,630.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,241.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,314.96,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,346.46,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
COMPONENT TIBIAL REMEDY LARGE,10605269,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5901.00,1770.30,2289.59,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2289.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5015.85,,,percent of total billed charges,,,2655.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIBIAL REMEDY LARGE,10605269,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5901.00,1770.30,2478.42,5015.85,,2891.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2478.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2976.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2507.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4425.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4425.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5015.85,,,percent of total billed charges,,,2714.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM RT 10MMX36CM 125DEG,10605270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM RT 10MMX36CM 125DEG,10605270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM RT 10MMX32CM 125DEG,10605271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM RT 10MMX32CM 125DEG,10605271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 46X28MM,10605272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 46X28MM,10605272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC HO 13X146MM,10605273,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC HO 13X146MM,10605273,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5MM 16X55MM,10605274,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1109.00,332.70,430.29,942.65,,,,,,,,,,,,,,,,,,,,430.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.65,,,percent of total billed charges,,,499.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5MM 16X55MM,10605274,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1109.00,332.70,471.32,942.65,,,,,,,,,,,,,service not payable,,,,,,,559.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,831.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,942.65,,,percent of total billed charges,,,510.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5MM 16X65MM,10605275,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1109.00,332.70,430.29,942.65,,,,,,,,,,,,,,,,,,,,430.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.65,,,percent of total billed charges,,,499.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5MM 16X65MM,10605275,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1109.00,332.70,471.32,942.65,,,,,,,,,,,,,service not payable,,,,,,,559.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,831.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,942.65,,,percent of total billed charges,,,510.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN BIOD ST FT 6.5X55MM,10605276,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1109.00,332.70,430.29,942.65,,,,,,,,,,,,,,,,,,,,430.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.65,,,percent of total billed charges,,,499.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN BIOD ST FT 6.5X55MM,10605276,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1109.00,332.70,471.32,942.65,,,,,,,,,,,,,service not payable,,,,,,,559.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,831.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,942.65,,,percent of total billed charges,,,510.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL CORIAL SZ13 135D,10605277,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1109.00,332.70,430.29,942.65,,,,,,,,,,,,,,,,,,,,430.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.65,,,percent of total billed charges,,,499.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL CORIAL SZ13 135D,10605277,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1109.00,332.70,471.32,942.65,,,,,,,,,,,,,service not payable,,,,,,,559.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,831.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,942.65,,,percent of total billed charges,,,510.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH ANG CONTALATERAL 5F 65CM X_31-5250 X_BOSTON S,10605441,CDM,0272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,85.00,25.50,36.13,72.25,,52.53,,,percent of total billed charges,,,,,,,,service not payable,41.48,,,percent of total billed charges,,,42.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,36.13,,,percent of total billed charges,,,,,,,,,63.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,,,,,,service not payable,63.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,72.25,,,percent of total billed charges,,,39.10,,,percent of total billed charges,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,55.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACET ENDO II 53MM,10605442,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACET ENDO II 53MM,10605442,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO PROX 13/145,10605443,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4524.00,1357.20,1755.31,3845.40,,,,,,,,,,,,,,,,,,,,1755.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1922.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3845.40,,,percent of total billed charges,,,2035.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO PROX 13/145,10605443,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4524.00,1357.20,1922.7,3845.40,,,,,,,,,,,,,service not payable,,,,,,,2281.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1922.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3845.40,,,percent of total billed charges,,,2081.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC NCB PROT 80X5MM,10605444,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,651.00,195.30,252.59,553.35,,,,,,,,,,,,,,,,,,,,252.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,488.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,325.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.35,,,percent of total billed charges,,,292.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC NCB PROT 80X5MM,10605444,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,651.00,195.30,276.68,553.35,,,,,,,,,,,,,service not payable,,,,,,,328.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,276.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,488.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,325.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,488.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,553.35,,,percent of total billed charges,,,299.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ6 RT,10605445,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ6 RT,10605445,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART 10MM RT 6-7 EF,10605446,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART 10MM RT 6-7 EF,10605446,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 9X25X0DEG,10605447,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 9X25X0DEG,10605447,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE NITI DT .062,10605448,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,268.00,80.40,113.90,227.80,,165.62,,,percent of total billed charges,,,,,,,,service not payable,130.78,,,percent of total billed charges,,,135.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,113.90,,,percent of total billed charges,,,,,,,,,201.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,134.0,,,percent of total billed charges,,,,,,,,service not payable,201.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,227.80,,,percent of total billed charges,,,123.28,,,percent of total billed charges,,,,,,,,,174.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,174.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD YUKON CONTOURED 4.0X25MM,10605451,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD YUKON CONTOURED 4.0X25MM,10605451,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW POLY XIA 4X26MM,10605452,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW POLY XIA 4X26MM,10605452,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE BAYONET 3PK 2MM,10605453,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,140.00,42.00,54.32,119.0,,,,,,,,,,,,,,,,,,,,54.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.0,,,percent of total billed charges,,,63.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE BAYONET 3PK 2MM,10605453,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,140.00,42.00,59.5,119.0,,,,,,,,,,,,,service not payable,,,,,,,70.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,105.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,70.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,105.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,119.0,,,percent of total billed charges,,,64.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SWAN-GANZ CCOMBO V,10605603,CDM,0272,RC,C1759,HCPCS,,,,,,outpatient,facility,,,2486.00,745.80,1056.55,2113.10,,1536.35,,,percent of total billed charges,,,,,,,,service not payable,1213.17,,,percent of total billed charges,,,1253.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1056.55,,,percent of total billed charges,,,,,,,,,1864.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1243.0,,,percent of total billed charges,,,,,,,,service not payable,1864.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2113.10,,,percent of total billed charges,,,1143.56,,,percent of total billed charges,,,,,,,,,1615.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1615.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER AVS UNLIF 4D 9X20MM,10605606,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER AVS UNLIF 4D 9X20MM,10605606,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ9 RT,10605733,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ9 RT,10605733,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURFACE 13MM RT,10605734,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURFACE 13MM RT,10605734,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIB TI 10MMX38CM,10605735,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4161.00,1248.30,1614.47,3536.85,,,,,,,,,,,,,,,,,,,,1614.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1768.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3120.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2080.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3536.85,,,percent of total billed charges,,,1872.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIB TI 10MMX38CM,10605735,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4161.00,1248.30,1768.42,3536.85,,,,,,,,,,,,,service not payable,,,,,,,2098.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1768.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3120.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2080.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3120.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3536.85,,,percent of total billed charges,,,1914.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO SZ8 120MM TYPE1,10605736,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO SZ8 120MM TYPE1,10605736,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3.5X94MM 7HOLE,10605737,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3.5X94MM 7HOLE,10605737,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 1/3 THRD 4.0X46MM,10605738,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 1/3 THRD 4.0X46MM,10605738,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAPTER TAPER 3MM NECK,10605739,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADAPTER TAPER 3MM NECK,10605739,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANNULATED 4 X 48MM,10605740,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANNULATED 4 X 48MM,10605740,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANNULATED 4 X 50MM,10605741,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANNULATED 4 X 50MM,10605741,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT BRST INSPIR SSL 290CC,10605742,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,3591.00,1077.30,1393.31,3052.35,,,,,,,,,,,,,,,,,,,,1393.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3052.35,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT BRST INSPIR SSL 290CC,10605742,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,3591.00,1077.30,1526.18,3052.35,,,,,,,,,,,,,service not payable,,,,,,,1811.3,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1526.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2693.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1795.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2693.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3052.35,,,percent of total billed charges,,,1651.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 120X10.5MM,10605743,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2337.00,701.10,906.76,1986.45,,,,,,,,,,,,,,,,,,,,906.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1752.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1168.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1986.45,,,percent of total billed charges,,,1051.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 120X10.5MM,10605743,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2337.00,701.10,993.23,1986.45,,,,,,,,,,,,,service not payable,,,,,,,1178.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,993.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1752.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1168.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1752.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1986.45,,,percent of total billed charges,,,1075.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SET TITANIUM 3.5X8MM,10605744,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,837.00,251.10,324.76,711.45,,,,,,,,,,,,,,,,,,,,324.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,627.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.45,,,percent of total billed charges,,,376.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SET TITANIUM 3.5X8MM,10605744,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,837.00,251.10,355.72,711.45,,,,,,,,,,,,,service not payable,,,,,,,422.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,355.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,627.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,418.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,627.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,711.45,,,percent of total billed charges,,,385.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE OLECRANON 13 HOLE,10605745,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3384.00,1015.20,1312.99,2876.40,,,,,,,,,,,,,,,,,,,,1312.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1438.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2538.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1692.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2876.40,,,percent of total billed charges,,,1522.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE OLECRANON 13 HOLE,10605745,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3384.00,1015.20,1438.2,2876.40,,,,,,,,,,,,,service not payable,,,,,,,1706.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1438.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2538.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1692.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2538.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2876.40,,,percent of total billed charges,,,1556.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LCKG 3.5X16MM,10605746,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,711.00,213.30,275.87,604.35,,,,,,,,,,,,,,,,,,,,275.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.35,,,percent of total billed charges,,,319.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LCKG 3.5X16MM,10605746,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,711.00,213.30,302.18,604.35,,,,,,,,,,,,,service not payable,,,,,,,358.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,302.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,533.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,355.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,533.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,604.35,,,percent of total billed charges,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WASHER SCREW LOW PROFILE 3.5,10605747,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,323.00,96.90,125.32,274.55,,,,,,,,,,,,,,,,,,,,125.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.55,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WASHER SCREW LOW PROFILE 3.5,10605747,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,323.00,96.90,137.28,274.55,,,,,,,,,,,,,service not payable,,,,,,,162.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,137.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,242.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,242.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,274.55,,,percent of total billed charges,,,148.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X44MM,10605748,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X44MM,10605748,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X46MM,10605749,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X46MM,10605749,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART 10MM RT 6-9CD,10605750,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART 10MM RT 6-9CD,10605750,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ALLOGRAFT OSTEO CART 20X25MM,10606143,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,24041.00,7212.30,9327.91,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9327.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20434.85,,,percent of total billed charges,,,10818.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOGRAFT OSTEO CART 20X25MM,10606143,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,24041.00,7212.30,10097.22,20434.85,,11780.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10097.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12126.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10217.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18030.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12020.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18030.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,20434.85,,,percent of total billed charges,,,11058.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 28X44MM,10606144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 28X44MM,10606144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 11X142MM,10606145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 11X142MM,10606145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR G7 36MM SZ E,10606146,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR G7 36MM SZ E,10606146,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM LT 10MMX38CM 125 DEG,10606147,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM LT 10MMX38CM 125 DEG,10606147,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ11 REDUCED NECK,10606148,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ11 REDUCED NECK,10606148,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURFACE 11MM LT,10606149,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURFACE 11MM LT,10606149,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT FIBERTAK DISPOSABLES 2.6,10606150,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1066.00,319.80,413.61,906.10,,,,,,,,,,,,,,,,,,,,413.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,,479.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT FIBERTAK DISPOSABLES 2.6,10606150,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1066.00,319.80,453.05,906.10,,,,,,,,,,,,,service not payable,,,,,,,537.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,453.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,799.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,533.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,799.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,,490.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE T SHAPE 8 H 1.4MM,10606151,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE T SHAPE 8 H 1.4MM,10606151,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SMARTNAIL FIXATION 1.5X16MM,10606152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1033.00,309.90,400.80,878.05,,,,,,,,,,,,,,,,,,,,400.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,,464.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SMARTNAIL FIXATION 1.5X16MM,10606152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1033.00,309.90,439.02,878.05,,,,,,,,,,,,,service not payable,,,,,,,521.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,,475.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SMARTNAIL FIXATION 1.5X20MM,10606153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1033.00,309.90,400.80,878.05,,,,,,,,,,,,,,,,,,,,400.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,,464.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SMARTNAIL FIXATION 1.5X20MM,10606153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1033.00,309.90,439.02,878.05,,,,,,,,,,,,,service not payable,,,,,,,521.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,,475.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SMARTNAIL FIXATION 1.5X25MM,10606154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1033.00,309.90,400.80,878.05,,,,,,,,,,,,,,,,,,,,400.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,,464.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SMARTNAIL FIXATION 1.5X25MM,10606154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1033.00,309.90,439.02,878.05,,,,,,,,,,,,,service not payable,,,,,,,521.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,,475.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SMARTNAIL FIXATION 2.4X16MM,10606155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1033.00,309.90,400.80,878.05,,,,,,,,,,,,,,,,,,,,400.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,,464.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SMARTNAIL FIXATION 2.4X16MM,10606155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1033.00,309.90,439.02,878.05,,,,,,,,,,,,,service not payable,,,,,,,521.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,,475.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SMARTNAIL FIXATION 2.4X25MM,10606156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1033.00,309.90,400.80,878.05,,,,,,,,,,,,,,,,,,,,400.80,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.05,,,percent of total billed charges,,,464.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SMARTNAIL FIXATION 2.4X25MM,10606156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1033.00,309.90,439.02,878.05,,,,,,,,,,,,,service not payable,,,,,,,521.05,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,439.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,774.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,516.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,774.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,878.05,,,percent of total billed charges,,,475.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR 24X61MM MED,10606157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3423.00,1026.90,1328.12,2909.55,,,,,,,,,,,,,,,,,,,,1328.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1454.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2567.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1711.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2909.55,,,percent of total billed charges,,,1540.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR 24X61MM MED,10606157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3423.00,1026.90,1454.77,2909.55,,,,,,,,,,,,,service not payable,,,,,,,1726.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1454.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2567.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1711.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2567.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2909.55,,,percent of total billed charges,,,1574.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR JUGGERKT MINI 1.0MM,10606159,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1143.00,342.90,443.48,971.55,,,,,,,,,,,,,,,,,,,,443.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,857.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,571.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,971.55,,,percent of total billed charges,,,514.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR JUGGERKT MINI 1.0MM,10606159,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1143.00,342.90,485.77,971.55,,,,,,,,,,,,,service not payable,,,,,,,576.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,485.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,857.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,571.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,857.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,971.55,,,percent of total billed charges,,,525.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FT SM HEX 4X10MM,10606160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FT SM HEX 4X10MM,10606160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIB 6H DIST LT 95MM,10606161,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIB 6H DIST LT 95MM,10606161,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAV SUP RT 8H 90MM,10606162,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3895.00,1168.50,1511.26,3310.75,,,,,,,,,,,,,,,,,,,,1511.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3310.75,,,percent of total billed charges,,,1752.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAV SUP RT 8H 90MM,10606162,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3895.00,1168.50,1655.38,3310.75,,,,,,,,,,,,,service not payable,,,,,,,1964.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3310.75,,,percent of total billed charges,,,1791.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT T15 LP 3.5X12MM,10606163,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT T15 LP 3.5X12MM,10606163,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 1.5X16MM NON-LOCK,10606165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 1.5X16MM NON-LOCK,10606165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 1.5X18MM NON-LOCK,10606166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 1.5X18MM NON-LOCK,10606166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 1.5X22MM NON-LOCK,10606167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 1.5X22MM NON-LOCK,10606167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING 1.5X18MM,10606168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING 1.5X18MM,10606168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING 1.5X20MM,10606169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,394.00,118.20,152.87,334.90,,,,,,,,,,,,,,,,,,,,152.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.90,,,percent of total billed charges,,,177.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING 1.5X20MM,10606169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,394.00,118.20,167.45,334.90,,,,,,,,,,,,,service not payable,,,,,,,198.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,167.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,295.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,197.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,295.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,334.90,,,percent of total billed charges,,,181.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE Y-SHAPE 12.9X43.7MM,10606171,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2484.00,745.20,963.79,2111.40,,,,,,,,,,,,,,,,,,,,963.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1055.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1863.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1242.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2111.40,,,percent of total billed charges,,,1117.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE Y-SHAPE 12.9X43.7MM,10606171,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2484.00,745.20,1055.7,2111.40,,,,,,,,,,,,,service not payable,,,,,,,1252.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1055.7,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1863.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1242.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1863.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2111.40,,,percent of total billed charges,,,1142.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NLK FT 2.5X12MM,10606172,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,419.00,125.70,162.57,356.15,,,,,,,,,,,,,,,,,,,,162.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,314.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.15,,,percent of total billed charges,,,188.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NLK FT 2.5X12MM,10606172,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,419.00,125.70,178.07,356.15,,,,,,,,,,,,,service not payable,,,,,,,211.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,314.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,209.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,314.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,356.15,,,percent of total billed charges,,,192.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NLK FT 2.5X10MM,10606173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,419.00,125.70,162.57,356.15,,,,,,,,,,,,,,,,,,,,162.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,314.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.15,,,percent of total billed charges,,,188.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NLK FT 2.5X10MM,10606173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,419.00,125.70,178.07,356.15,,,,,,,,,,,,,service not payable,,,,,,,211.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,178.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,314.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,209.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,314.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,356.15,,,percent of total billed charges,,,192.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TAK BB MTP THREADED,10606174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAK BB MTP THREADED,10606174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MAXFORCE RT 0 DEG,10606175,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,26215.00,7864.50,10171.42,22282.75,,12845.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11010.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10171.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11141.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19661.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13107.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22282.75,,,percent of total billed charges,,,11796.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MAXFORCE RT 0 DEG,10606175,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,26215.00,7864.50,11010.30,22282.75,,12845.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11010.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13222.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11141.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19661.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13107.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19661.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,22282.75,,,percent of total billed charges,,,12058.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE RT 11MM 3-5CD,10606176,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE RT 11MM 3-5CD,10606176,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ALL-POLY PATELLA 29MM 8MM,10606177,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ALL-POLY PATELLA 29MM 8MM,10606177,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE SRD RT SZ 4,10606178,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE SRD RT SZ 4,10606178,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIB SZ7 14MM,10606179,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIB SZ7 14MM,10606179,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LIFESTENT 5F 135CM 5X100MM,10606180,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIFESTENT 5F 135CM 5X100MM,10606180,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 10MMX32CM 130D RT,10606182,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5706.00,1711.80,2213.93,4850.10,,2795.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2396.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2213.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2425.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4279.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2853.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4850.10,,,percent of total billed charges,,,2567.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 10MMX32CM 130D RT,10606182,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5706.00,1711.80,2396.52,4850.10,,2795.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2396.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2878.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2425.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4279.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2853.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4279.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4850.10,,,percent of total billed charges,,,2624.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ11 LT,10606692,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ11 LT,10606692,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SYSTEM MITRACLIP G4,10606694,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,65564.00,19669.20,25438.83,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,25438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55729.40,,,percent of total billed charges,,,29503.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM MITRACLIP G4,10606694,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,65564.00,19669.20,27536.88,55729.40,,32126.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,27536.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,33070.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,27864.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32782.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,49173.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55729.40,,,percent of total billed charges,,,30159.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 135CM 5X170MM,10606701,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 135CM 5X170MM,10606701,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 135CM 6X80MM,10606702,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 135CM 6X80MM,10606702,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 135CM 7X120MM,10606703,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 135CM 7X120MM,10606703,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST CPX4 MED 800ML,10606704,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST CPX4 MED 800ML,10606704,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST CPX4 TALL 750ML,10606705,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST CPX4 TALL 750ML,10606705,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST CPX4 TALL 850ML,10606706,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST CPX4 TALL 850ML,10606706,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPDR BRST CPX4 TALL 850ML,10606707,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPDR BRST CPX4 TALL 850ML,10606707,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MM Exam,10606967,CDM,0361,RC,19281,CPT,,,,,LT  ,outpatient,facility,,,1707.00,512.10,785.22,3666.78,,1707.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,861.01,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1450.95,,,percent of total billed charges,,,785.22,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MM Exam,10606967,CDM,0361,RC,19281,CPT,05072,APC,,,LT  ,outpatient,facility,,,1707.00,512.10,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
MM Exam,10606967,CDM,0361,RC,19281,CPT,20,EAPG,,,LT  ,outpatient,facility,,,1707.00,512.10,1707.0,3527.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2998.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1707.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1707.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2342.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2576.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MM Exam,10606969,CDM,0361,RC,19281,CPT,,,,,RT  ,outpatient,facility,,,1707.00,512.10,785.22,3666.78,,1707.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,861.01,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2320.0,,,case rate,,,,,,,,,1280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1450.95,,,percent of total billed charges,,,785.22,,,percent of total billed charges,,,,,,,,,3044.0,,,case rate,,,,,,,,,,,,,,,2679.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MM Exam,10606969,CDM,0361,RC,19281,CPT,05072,APC,,,RT  ,outpatient,facility,,,1707.00,512.10,1490.34,3568.59,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3268.57,,,fee schedule,,,1490.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1584.84,,,fee schedule,,,3568.59,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,3221.20,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,1490.34,,,fee schedule,,,1584.84,,,fee schedule,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1490.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1584.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,,,,,,,1553.76,,,fee schedule,,,,,,,,,1569.23,,,fee schedule,,,,,,,,
MM Exam,10606969,CDM,0361,RC,19281,CPT,20,EAPG,,,RT  ,outpatient,facility,,,1707.00,512.10,1707.0,3527.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2998.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1707.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1707.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1707.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2342.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2576.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MM Exam,10606971,CDM,0361,RC,19283,CPT,,,,,LT  ,outpatient,facility,,,2400.00,720.00,1104.0,3666.78,,2400.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,1210.56,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1800.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1800.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2040.0,,,percent of total billed charges,,,1104.0,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MM Exam,10606971,CDM,0361,RC,19283,CPT,05071,APC,,,LT  ,outpatient,facility,,,2400.00,720.00,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
MM Exam,10606971,CDM,0361,RC,19283,CPT,20,EAPG,,,LT  ,outpatient,facility,,,2400.00,720.00,1935.39,3527.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2998.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2342.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2576.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MM Exam,10606973,CDM,0361,RC,19283,CPT,,,,,RT  ,outpatient,facility,,,2400.00,720.00,1104.0,3666.78,,2400.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,1210.56,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1800.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1800.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2040.0,,,percent of total billed charges,,,1104.0,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
MM Exam,10606973,CDM,0361,RC,19283,CPT,05071,APC,,,RT  ,outpatient,facility,,,2400.00,720.00,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
MM Exam,10606973,CDM,0361,RC,19283,CPT,20,EAPG,,,RT  ,outpatient,facility,,,2400.00,720.00,1935.39,3527.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2998.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2342.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2576.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
US Breast Exam,10607010,CDM,0402,RC,19285,CPT,,,,,LT  ,outpatient,facility,,,2255.00,676.50,958.38,1916.75,,1393.59,,,percent of total billed charges,,,,,,,,,1100.44,,,percent of total billed charges,,,1137.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,958.38,,,percent of total billed charges,,,,,,,,,1691.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1127.5,,,percent of total billed charges,,,,,,,,,1691.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1916.75,,,percent of total billed charges,,,1037.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
US Breast Exam,10607010,CDM,0402,RC,19285,CPT,05071,APC,,,LT  ,outpatient,facility,,,2255.00,676.50,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
US Breast Exam,10607010,CDM,0402,RC,19285,CPT,20,EAPG,,,LT  ,outpatient,facility,,,2255.00,676.50,1935.39,3527.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2998.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2342.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2576.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
US Breast Exam,10607012,CDM,0402,RC,19285,CPT,,,,,RT  ,outpatient,facility,,,2255.00,676.50,958.38,1916.75,,1393.59,,,percent of total billed charges,,,,,,,,,1100.44,,,percent of total billed charges,,,1137.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,958.38,,,percent of total billed charges,,,,,,,,,1691.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1127.5,,,percent of total billed charges,,,,,,,,,1691.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1916.75,,,percent of total billed charges,,,1037.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
US Breast Exam,10607012,CDM,0402,RC,19285,CPT,05071,APC,,,RT  ,outpatient,facility,,,2255.00,676.50,647.18,1549.66,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1419.38,,,fee schedule,,,647.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",688.21,,,fee schedule,,,1549.66,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,1398.81,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,647.18,,,fee schedule,,,688.21,,,fee schedule,,,,,,,,,674.72,,,fee schedule,,,,,,,,,647.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",688.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,,,,,,,674.72,,,fee schedule,,,,,,,,,681.44,,,fee schedule,,,,,,,,
US Breast Exam,10607012,CDM,0402,RC,19285,CPT,20,EAPG,,,RT  ,outpatient,facility,,,2255.00,676.50,1935.39,3527.70,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.70,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2998.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1935.39,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2342.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2576.60,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Tenotomy percutaneous toe single tendon,10607013,CDM,0761,RC,28010,CPT,,,,,,outpatient,facility,,,4399.00,1319.70,118.0,3739.15,,2718.58,,,percent of total billed charges,,,,,,,,,2146.71,,,percent of total billed charges,,,2218.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1869.58,,,percent of total billed charges,,,,,,,,,3299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2199.5,,,percent of total billed charges,,,,,,,,,3299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3739.15,,,percent of total billed charges,,,2023.54,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Tenotomy percutaneous toe single tendon,10607013,CDM,0761,RC,28010,CPT,05112,APC,,,,outpatient,facility,,,4399.00,1319.70,1472.10,3524.92,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3228.58,,,fee schedule,,,1472.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1565.43,,,fee schedule,,,3524.92,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3181.79,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,1472.10,,,fee schedule,,,1565.43,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,1472.10,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1565.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,1550.03,,,fee schedule,,,,,,,,
WC-Tenotomy percutaneous toe single tendon,10607013,CDM,0761,RC,28010,CPT,35,EAPG,,,,outpatient,facility,,,4399.00,1319.70,3109.33,6931.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6931.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5891.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4173.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4591.22,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Fasciectomy plantar fascia partial,10607014,CDM,0761,RC,28060,CPT,,,,,,outpatient,facility,,,8939.00,2681.70,118.0,7598.15,,5524.30,,,percent of total billed charges,,,,,,,,,4362.23,,,percent of total billed charges,,,4508.83,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3799.07,,,percent of total billed charges,,,,,,,,,6704.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4469.5,,,percent of total billed charges,,,,,,,,,6704.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7598.15,,,percent of total billed charges,,,4111.94,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Fasciectomy plantar fascia partial,10607014,CDM,0761,RC,28060,CPT,05113,APC,,,,outpatient,facility,,,8939.00,2681.70,2984.48,7146.28,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6545.48,,,fee schedule,,,2984.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3173.71,,,fee schedule,,,7146.28,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6450.62,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,2984.48,,,fee schedule,,,3173.71,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,2984.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3173.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,3142.46,,,fee schedule,,,,,,,,
WC-Fasciectomy plantar fascia partial,10607014,CDM,0761,RC,28060,CPT,35,EAPG,,,,outpatient,facility,,,8939.00,2681.70,3109.33,6931.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6931.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5891.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4173.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4591.22,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Interphalangeal joint each joint,10607015,CDM,0761,RC,28272,CPT,,,,,,outpatient,facility,,,4399.00,1319.70,118.0,3739.15,,2718.58,,,percent of total billed charges,,,,,,,,,2146.71,,,percent of total billed charges,,,2218.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1869.58,,,percent of total billed charges,,,,,,,,,3299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2199.5,,,percent of total billed charges,,,,,,,,,3299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3739.15,,,percent of total billed charges,,,2023.54,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Interphalangeal joint each joint,10607015,CDM,0761,RC,28272,CPT,05112,APC,,,,outpatient,facility,,,4399.00,1319.70,1472.10,3524.92,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3228.58,,,fee schedule,,,1472.10,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1565.43,,,fee schedule,,,3524.92,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,3181.79,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,1472.10,,,fee schedule,,,1565.43,,,fee schedule,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,1472.10,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1565.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,,,,,,,1534.74,,,fee schedule,,,,,,,,,1550.03,,,fee schedule,,,,,,,,
WC-Interphalangeal joint each joint,10607015,CDM,0761,RC,28272,CPT,35,EAPG,,,,outpatient,facility,,,4399.00,1319.70,3109.33,6931.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6931.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5891.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4173.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4591.22,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
WC-Non Selective Debridement w/larvae application,10607028,CDM,0761,RC,97602,CPT,,,,,,outpatient,facility,,,689.00,206.70,118.0,585.65,,425.80,,,percent of total billed charges,,,,,,,,,336.23,,,percent of total billed charges,,,347.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.82,,,percent of total billed charges,,,,,,,,,516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,344.5,,,percent of total billed charges,,,,,,,,,516.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,585.65,,,percent of total billed charges,,,316.94,,,percent of total billed charges,,,,,,,,,134.0,,,per diem,,,,,,,,,,,,,,,118.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Non Selective Debridement w/larvae application,10607028,CDM,0761,RC,97602,CPT,05051,APC,,,,outpatient,facility,,,689.00,206.70,182.77,437.65,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,400.86,,,fee schedule,,,182.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",194.36,,,fee schedule,,,437.65,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,395.05,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,182.77,,,fee schedule,,,194.36,,,fee schedule,,,,,,,,,190.55,,,fee schedule,,,,,,,,,182.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",194.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,,,,,,,190.55,,,fee schedule,,,,,,,,,192.45,,,fee schedule,,,,,,,,
WC-Non Selective Debridement w/larvae application,10607028,CDM,0761,RC,97602,CPT,17,EAPG,,,,outpatient,facility,,,689.00,206.70,555.36,1321.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1123.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,555.36,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,925.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1018.23,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Mag Seed 18g-12cm,10607096,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,1171.00,351.30,454.35,995.35,,,,,,,,,,,,,,,,,,,,454.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,497.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,878.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,585.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,995.35,,,percent of total billed charges,,,526.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Mag Seed 18g-12cm,10607096,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,1171.00,351.30,497.68,995.35,,,,,,,,,,,,,service not payable,,,,,,,590.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,497.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,878.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,585.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,878.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,995.35,,,percent of total billed charges,,,538.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Mag Seed 18g-12cm,10607097,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,1171.00,351.30,454.35,995.35,,,,,,,,,,,,,,,,,,,,454.35,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,497.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,878.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,585.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,995.35,,,percent of total billed charges,,,526.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Mag Seed 18g-12cm,10607097,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,1171.00,351.30,497.68,995.35,,,,,,,,,,,,,service not payable,,,,,,,590.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,497.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,878.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,585.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,878.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,995.35,,,percent of total billed charges,,,538.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EXPANDER BRST CPX4 MED 650ML,10608247,CDM,0278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6310.00,1893.00,2448.28,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2448.28,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5363.5,,,percent of total billed charges,,,2839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXPANDER BRST CPX4 MED 650ML,10608247,CDM,0278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6310.00,1893.00,2650.20,5363.5,,3091.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2650.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3182.76,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2681.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4732.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3155.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4732.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5363.5,,,percent of total billed charges,,,2902.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EMBOLECTOMY 3F 40CM,10608248,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,276.00,82.80,117.3,234.60,,170.57,,,percent of total billed charges,,,,,,,,service not payable,134.69,,,percent of total billed charges,,,139.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,117.3,,,percent of total billed charges,,,,,,,,,207.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,138.0,,,percent of total billed charges,,,,,,,,service not payable,207.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,234.60,,,percent of total billed charges,,,126.96,,,percent of total billed charges,,,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EMBOLECTOMY 4F 40CM,10608249,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,276.00,82.80,117.3,234.60,,170.57,,,percent of total billed charges,,,,,,,,service not payable,134.69,,,percent of total billed charges,,,139.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,117.3,,,percent of total billed charges,,,,,,,,,207.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,138.0,,,percent of total billed charges,,,,,,,,service not payable,207.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,234.60,,,percent of total billed charges,,,126.96,,,percent of total billed charges,,,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH EMBOLECTOMY 7F 80CM,10608250,CDM,0272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,276.00,82.80,117.3,234.60,,170.57,,,percent of total billed charges,,,,,,,,service not payable,134.69,,,percent of total billed charges,,,139.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,117.3,,,percent of total billed charges,,,,,,,,,207.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,138.0,,,percent of total billed charges,,,,,,,,service not payable,207.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,234.60,,,percent of total billed charges,,,126.96,,,percent of total billed charges,,,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,179.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ E LT 4-6X10MM,10608251,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ E LT 4-6X10MM,10608251,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL BEARING PS 14MM 79/83,10608252,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL BEARING PS 14MM 79/83,10608252,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM MOD 40MM MINUS 6MM,10608253,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM MOD 40MM MINUS 6MM,10608253,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS TORIC 22.0D,10608258,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC 22.0D,10608258,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
BB Ref RBC Genotyping,10608517,CDM,0300,RC,0084U,CPT,,,,,59  ,outpatient,facility,,,425.00,127.50,195.5,1501.56,,262.65,,,percent of total billed charges,,,416.5,,,fee schedule,,,209.10,,,fee schedule,,,1501.56,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,879.75,,,fee schedule,,,425.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",424.83,,,fee schedule,,,960.50,,,fee schedule,,,,,,,,,416.5,,,fee schedule,,,,,,,,,926.37,,,fee schedule,,,867.0,,,fee schedule,,,318.75,,,percent of total billed charges,,,416.5,,,fee schedule,,,425.0,,,fee schedule,,,424.83,,,fee schedule,,,1089.46,,,fee schedule,,,416.5,,,fee schedule,,,318.75,,,percent of total billed charges,,,425.0,,,fee schedule,,,424.83,,,fee schedule,,,,,,,,,361.25,,,percent of total billed charges,,,195.5,,,percent of total billed charges,,,,,,,,,792.0,,,fee schedule,,,416.5,,,fee schedule,,,,,,,,,698.40,,,fee schedule,,,416.5,,,fee schedule,,,,,,,,,416.5,,,fee schedule,,,,,,,,
BB Ref RBC Genotyping,10608517,CDM,0300,RC,0084U,CPT,2044,EAPG,,,59  ,outpatient,facility,,,425.00,127.50,425.0,1300.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1105.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,425.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,425.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,527.62,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,580.38,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
KIT VALVE TAVR COMMANDR 20MM,10608539,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT VALVE TAVR COMMANDR 20MM,10608539,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT VALVE TAVR COMMANDR 23MM,10608544,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT VALVE TAVR COMMANDR 23MM,10608544,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT VALVE TAVR COMMANDR 26MM,10608546,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,71028.00,21308.40,27558.86,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,27558.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60373.80,,,percent of total billed charges,,,31962.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT VALVE TAVR COMMANDR 26MM,10608546,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,71028.00,21308.40,29831.76,60373.80,,34803.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,29831.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,35826.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,30186.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35514.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,53271.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,60373.80,,,percent of total billed charges,,,32672.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE MED SZH LT,10608548,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE MED SZH LT,10608548,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR PART SZ 7 LT,10608549,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR PART SZ 7 LT,10608549,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMUR PSN LT SZ8,10608550,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMUR PSN LT SZ8,10608550,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VPC 2.5X30MM,10608551,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VPC 2.5X30MM,10608551,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE PROLAYER MESH 5X8CM,10608553,CDM,0278,RC,Q4126,HCPCS,,,,,,inpatient,facility,,,12831.00,3849.30,4978.43,10906.35,,6287.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5389.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4978.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5453.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9623.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6415.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10906.35,,,percent of total billed charges,,,5773.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE PROLAYER MESH 5X8CM,10608553,CDM,0278,RC,Q4126,HCPCS,,,,,,outpatient,facility,,,12831.00,3849.30,5389.02,10906.35,,6287.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5389.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6471.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5453.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9623.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6415.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9623.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10906.35,,,percent of total billed charges,,,5902.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE PROLAYER MESH 5X8CM,10608553,CDM,0278,RC,Q4126,HCPCS,2010,EAPG,,,,outpatient,facility,,,12831.00,3849.30,50.84,63.30,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,50.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.30,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,63.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CUP ACETABULAR RINGLOC 28X48MM,10608554,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 28X48MM,10608554,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC HO-1 10X140MM,10608555,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC HO-1 10X140MM,10608555,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID MOD 4 PEG SZ 5,10608556,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID MOD 4 PEG SZ 5,10608556,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID MOD POST TM,10608557,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1367.00,410.10,530.40,1161.95,,,,,,,,,,,,,,,,,,,,530.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.95,,,percent of total billed charges,,,615.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID MOD POST TM,10608557,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1367.00,410.10,580.98,1161.95,,,,,,,,,,,,,service not payable,,,,,,,689.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,580.98,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1025.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,683.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1025.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1161.95,,,percent of total billed charges,,,628.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXTENSION 3MM 10X135MM,10608558,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXTENSION 3MM 10X135MM,10608558,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE TIB PERS REV SZ S,10608559,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16801.00,5040.30,6518.79,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6518.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14280.85,,,percent of total billed charges,,,7560.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE TIB PERS REV SZ S,10608559,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16801.00,5040.30,7056.42,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8474.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14280.85,,,percent of total billed charges,,,7728.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV 14X75MM,10608560,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5278.00,1583.40,2047.86,4486.30,,2586.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2216.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2047.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2243.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3958.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2639.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4486.30,,,percent of total billed charges,,,2375.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV 14X75MM,10608560,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5278.00,1583.40,2216.76,4486.30,,2586.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2216.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2662.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2243.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3958.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2639.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3958.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4486.30,,,percent of total billed charges,,,2427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTICULAR PSN RT 12MM,10608561,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTICULAR PSN RT 12MM,10608561,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURFACE 12MM RT,10608562,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURFACE 12MM RT,10608562,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FEMORAL PSN 2.5X25MM,10608563,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,847.00,254.10,328.64,719.95,,,,,,,,,,,,,,,,,,,,328.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.95,,,percent of total billed charges,,,381.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FEMORAL PSN 2.5X25MM,10608563,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,847.00,254.10,359.97,719.95,,,,,,,,,,,,,service not payable,,,,,,,427.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,359.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,635.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,423.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,635.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,719.95,,,percent of total billed charges,,,389.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT MINI HEX 2.0X18MM,10608564,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT MINI HEX 2.0X18MM,10608564,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/4 TUBULAR 4H 31MM,10608565,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,384.00,115.20,148.99,326.40,,,,,,,,,,,,,,,,,,,,148.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,172.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/4 TUBULAR 4H 31MM,10608565,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,,,,,,,,,,,,service not payable,,,,,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SM HEX 2X40MM,10608566,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SM HEX 2X40MM,10608566,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7MM HEAD 3.5X54MM,10608567,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7MM HEAD 3.5X54MM,10608567,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANC FORTE PT 4.0X38MM,10609226,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,384.00,115.20,148.99,326.40,,,,,,,,,,,,,,,,,,,,148.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.40,,,percent of total billed charges,,,172.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANC FORTE PT 4.0X38MM,10609226,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,384.00,115.20,163.20,326.40,,,,,,,,,,,,,service not payable,,,,,,,193.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,163.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,288.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,192.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,288.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,326.40,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM RT 11.5MMX36CM 130DEG,10609227,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM RT 11.5MMX36CM 130DEG,10609227,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF LT 4-5 13MM EF,10609228,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF LT 4-5 13MM EF,10609228,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ5 LT,10609229,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ5 LT,10609229,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ5 RT,10609230,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ5 RT,10609230,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ALL-POLY PATELLA 26MM 8MM,10609231,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ALL-POLY PATELLA 26MM 8MM,10609231,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FIXED RT 4-5 CD 10MM,10609232,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FIXED RT 4-5 CD 10MM,10609232,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX TIB LOCK 9H RT,10609233,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3541.00,1062.30,1373.91,3009.85,,,,,,,,,,,,,,,,,,,,1373.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3009.85,,,percent of total billed charges,,,1593.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX TIB LOCK 9H RT,10609233,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3541.00,1062.30,1504.92,3009.85,,,,,,,,,,,,,service not payable,,,,,,,1786.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1504.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2655.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1770.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2655.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3009.85,,,percent of total billed charges,,,1628.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK LP 3.5X85MM,10609234,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK LP 3.5X85MM,10609234,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK LP 3.5X70MM,10609235,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK LP 3.5X70MM,10609235,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK LP 3.5X40MM,10609236,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK LP 3.5X40MM,10609236,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK LP 3.5X42MM,10609237,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK LP 3.5X42MM,10609237,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTI-D LOCK 3.5X75MM,10609238,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTI-D LOCK 3.5X75MM,10609238,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTI-D LOCK 3.5X80MM,10609239,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTI-D LOCK 3.5X80MM,10609239,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW MULTI-D LOCK 3.5X60MM,10609240,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW MULTI-D LOCK 3.5X60MM,10609240,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE LKG NS 6H 3.5MM,10609241,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2268.00,680.40,879.98,1927.8,,,,,,,,,,,,,,,,,,,,879.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,963.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1701.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1134.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1927.8,,,percent of total billed charges,,,1020.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE LKG NS 6H 3.5MM,10609241,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2268.00,680.40,963.90,1927.8,,,,,,,,,,,,,service not payable,,,,,,,1143.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,963.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1701.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1134.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1701.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1927.8,,,percent of total billed charges,,,1043.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 3.5X40MM,10609242,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,320.00,96.00,124.16,272.0,,,,,,,,,,,,,,,,,,,,124.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.0,,,percent of total billed charges,,,144.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 3.5X40MM,10609242,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,320.00,96.00,136.0,272.0,,,,,,,,,,,,,service not payable,,,,,,,161.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,240.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.0,,,percent of total billed charges,,,147.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 3.5X60MM,10609243,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,320.00,96.00,124.16,272.0,,,,,,,,,,,,,,,,,,,,124.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.0,,,percent of total billed charges,,,144.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 3.5X60MM,10609243,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,320.00,96.00,136.0,272.0,,,,,,,,,,,,,service not payable,,,,,,,161.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,240.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.0,,,percent of total billed charges,,,147.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW UNIV LK TI 3.5X14MM,10609244,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW UNIV LK TI 3.5X14MM,10609244,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW UNIV LK TI 3.5X16MM,10609245,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW UNIV LK TI 3.5X16MM,10609245,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR MULTI PC 13.0,10609246,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR MULTI PC 13.0,10609246,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR MULTI PC 13.5,10609247,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR MULTI PC 13.5,10609247,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR MULTI PC 16.0,10609248,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR MULTI PC 16.0,10609248,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS INTRAOCULAR MULTI PC 25.0,10609249,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR MULTI PC 25.0,10609249,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WC-Fasiotomy foot and/or toe,10609475,CDM,0490,RC,28008,CPT,,,,,,outpatient,facility,,,5715.00,1714.50,2628.90,5715.0,,5715.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,2882.65,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,4286.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,4286.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4857.75,,,percent of total billed charges,,,2628.90,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
WC-Fasiotomy foot and/or toe,10609475,CDM,0490,RC,28008,CPT,05113,APC,,,,outpatient,facility,,,5715.00,1714.50,2984.48,7146.28,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6545.48,,,fee schedule,,,2984.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3173.71,,,fee schedule,,,7146.28,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,6450.62,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,2984.48,,,fee schedule,,,3173.71,,,fee schedule,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,2984.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3173.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,,,,,,,3111.48,,,fee schedule,,,,,,,,,3142.46,,,fee schedule,,,,,,,,
WC-Fasiotomy foot and/or toe,10609475,CDM,0490,RC,28008,CPT,35,EAPG,,,,outpatient,facility,,,5715.00,1714.50,3109.33,6931.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6931.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,5891.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3109.33,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,4173.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4591.22,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SCREW CANNULATED 3.5 X 50MM,10609538,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,861.00,258.30,334.07,731.85,,,,,,,,,,,,,,,,,,,,334.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.85,,,percent of total billed charges,,,387.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANNULATED 3.5 X 50MM,10609538,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,861.00,258.30,365.93,731.85,,,,,,,,,,,,,service not payable,,,,,,,434.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,645.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,396.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CPM L 11.5MMX38CM 13D,10609539,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CPM L 11.5MMX38CM 13D,10609539,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD LT SZ 9,10609540,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD LT SZ 9,10609540,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURF CPS LT 16MM,10609541,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURF CPS LT 16MM,10609541,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER HYDR CERV LORDOTIC 10MM,10609542,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER HYDR CERV LORDOTIC 10MM,10609542,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Kit Tissue BioSurge II 5CC_Arthrex Inc_ABS-2016-02,10609544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5738.00,1721.40,2226.34,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2226.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4877.30,,,percent of total billed charges,,,2582.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Kit Tissue BioSurge II 5CC_Arthrex Inc_ABS-2016-02,10609544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5738.00,1721.40,2409.96,4877.30,,2811.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2409.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2894.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2438.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4303.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4303.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4877.30,,,percent of total billed charges,,,2639.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT BONE MARROW ASP ND 30ML,10609545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4263.00,1278.90,1654.04,3623.55,,,,,,,,,,,,,,,,,,,,1654.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3623.55,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT BONE MARROW ASP ND 30ML,10609545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4263.00,1278.90,1811.77,3623.55,,,,,,,,,,,,,service not payable,,,,,,,2150.26,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1811.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3197.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2131.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3197.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3623.55,,,percent of total billed charges,,,1960.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 6.5X50MM FULL THD,10609546,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1109.00,332.70,430.29,942.65,,,,,,,,,,,,,,,,,,,,430.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.65,,,percent of total billed charges,,,499.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 6.5X50MM FULL THD,10609546,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1109.00,332.70,471.32,942.65,,,,,,,,,,,,,service not payable,,,,,,,559.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,471.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,831.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,554.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,831.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,942.65,,,percent of total billed charges,,,510.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TISSUE DBM BONUS FIBER 5CC,10609547,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3600.00,1080.00,1396.8,3060.0,,,,,,,,,,,,,,,,,,,,1396.8,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1530.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2700.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1800.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3060.0,,,percent of total billed charges,,,1620.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TISSUE DBM BONUS FIBER 5CC,10609547,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3600.00,1080.00,1530.0,3060.0,,,,,,,,,,,,,service not payable,,,,,,,1815.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1530.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2700.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1800.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2700.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3060.0,,,percent of total billed charges,,,1656.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX ULNAR CLK 5H LEFT,10609548,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3147.00,944.10,1221.04,2674.95,,,,,,,,,,,,,,,,,,,,1221.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2360.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1573.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.95,,,percent of total billed charges,,,1416.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX ULNAR CLK 5H LEFT,10609548,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3147.00,944.10,1337.47,2674.95,,,,,,,,,,,,,service not payable,,,,,,,1587.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1337.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2360.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1573.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2360.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2674.95,,,percent of total billed charges,,,1447.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SM HEX 2.7X45MM,10609549,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SM HEX 2.7X45MM,10609549,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VPC 3.4X18MM,10609550,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VPC 3.4X18MM,10609550,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT SHAFT ULNA 101 159MM FZ,10609551,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4016.00,1204.80,1558.21,3413.60,,,,,,,,,,,,,,,,,,,,1558.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1706.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3012.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.60,,,percent of total billed charges,,,1807.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT SHAFT ULNA 101 159MM FZ,10609551,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4016.00,1204.80,1706.8,3413.60,,,,,,,,,,,,,service not payable,,,,,,,2025.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1706.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3012.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2008.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3012.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3413.60,,,percent of total billed charges,,,1847.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ARTICULAR SURFACE LM SZH 8MM,10609552,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTICULAR SURFACE LM SZH 8MM,10609552,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID PEG 3 SZ4,10609553,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID PEG 3 SZ4,10609553,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR HUM STEM-FREE LT,10609554,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,12295.00,3688.50,4770.46,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4770.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10450.75,,,percent of total billed charges,,,5532.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR HUM STEM-FREE LT,10609554,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,12295.00,3688.50,5163.90,10450.75,,6024.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6201.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5225.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,10450.75,,,percent of total billed charges,,,5655.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUERAL SHOULDER STEM FREE,10609555,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUERAL SHOULDER STEM FREE,10609555,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM REDAPT SZ16 240MM,10609556,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24113.00,7233.90,9355.84,20496.05,,11815.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10127.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9355.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10248.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18084.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12056.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20496.05,,,percent of total billed charges,,,10850.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM REDAPT SZ16 240MM,10609556,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24113.00,7233.90,10127.46,20496.05,,11815.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10127.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12162.6,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10248.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18084.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12056.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18084.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20496.05,,,percent of total billed charges,,,11091.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR SIZE 12 LEFT,10609563,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR SIZE 12 LEFT,10609563,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP PERSONA TIBIA LEFT SZ H,10609564,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP PERSONA TIBIA LEFT SZ H,10609564,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SUR PSN 14MM LT,10609565,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SUR PSN 14MM LT,10609565,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT L LATERAL 10MM,10609566,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT L LATERAL 10MM,10609566,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL PSN AUGMENT LM 10MM,10609567,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL PSN AUGMENT LM 10MM,10609567,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB FIXED PSN LT SZ E,10609568,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB FIXED PSN LT SZ E,10609568,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ART SURF REV CCK 7-9 EF 18MM,10609569,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ART SURF REV CCK 7-9 EF 18MM,10609569,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PERS LT SZ 7,10609570,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23357.00,7007.10,9062.52,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9062.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19853.45,,,percent of total billed charges,,,10510.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PERS LT SZ 7,10609570,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23357.00,7007.10,9809.94,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11781.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19853.45,,,percent of total billed charges,,,10744.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT STR SPLINE 135X15MM,10609571,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5655.00,1696.50,2194.14,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2194.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4806.75,,,percent of total billed charges,,,2544.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT STR SPLINE 135X15MM,10609571,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5655.00,1696.50,2375.10,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2852.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4806.75,,,percent of total billed charges,,,2601.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PROX 14 X 111.5MM,10609572,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PROX 14 X 111.5MM,10609572,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DISTAL CENTRALIZER SZ 9,10609573,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,520.00,156.00,201.76,442.0,,,,,,,,,,,,,,,,,,,,201.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.0,,,percent of total billed charges,,,234.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DISTAL CENTRALIZER SZ 9,10609573,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,,,,,,,,,,,,service not payable,,,,,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FIBULA DIST 7HRT 3.5MM,10609574,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3548.00,1064.40,1376.62,3015.80,,,,,,,,,,,,,,,,,,,,1376.62,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1507.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2661.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1774.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3015.80,,,percent of total billed charges,,,1596.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FIBULA DIST 7HRT 3.5MM,10609574,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3548.00,1064.40,1507.90,3015.80,,,,,,,,,,,,,service not payable,,,,,,,1789.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1507.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2661.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1774.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2661.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3015.80,,,percent of total billed charges,,,1632.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDE WIRE JUGGERLOC 2.9,10609923,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,372.04,,,percent of total billed charges,,,,,,,,service not payable,293.78,,,percent of total billed charges,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,391.30,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 16MM 6.5X45MM,10609924,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1107.00,332.10,429.52,940.95,,,,,,,,,,,,,,,,,,,,429.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,830.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,940.95,,,percent of total billed charges,,,498.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 16MM 6.5X45MM,10609924,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1107.00,332.10,470.47,940.95,,,,,,,,,,,,,service not payable,,,,,,,558.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,470.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,830.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,553.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,830.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,940.95,,,percent of total billed charges,,,509.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 47X28MM,10609925,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 47X28MM,10609925,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 10X140MM,10609926,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 10X140MM,10609926,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 TRAITH 11MM,10609927,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 TRAITH 11MM,10609927,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FIBULOCK 3.8X130MM RT,10609928,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,9819.00,2945.70,3809.77,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3809.77,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8346.15,,,percent of total billed charges,,,4418.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FIBULOCK 3.8X130MM RT,10609928,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,9819.00,2945.70,4123.98,8346.15,,4811.31,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4123.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4952.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4173.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7364.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4909.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7364.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8346.15,,,percent of total billed charges,,,4516.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLUG FISTULA ANAL 0.7CM,10609929,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4081.00,1224.30,1583.43,3468.85,,,,,,,,,,,,,,,,,,,,1583.43,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1734.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3060.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2040.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3468.85,,,percent of total billed charges,,,1836.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLUG FISTULA ANAL 0.7CM,10609929,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4081.00,1224.30,1734.42,3468.85,,,,,,,,,,,,,service not payable,,,,,,,2058.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1734.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3060.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2040.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3060.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3468.85,,,percent of total billed charges,,,1877.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X58MM,10609930,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X58MM,10609930,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTAP SH 3.5X30MM,10609932,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTAP SH 3.5X30MM,10609932,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURFACE 10MM LT,10609933,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURFACE 10MM LT,10609933,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR PSN SZ5 RT,10609934,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR PSN SZ5 RT,10609934,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE RT 6-9 EF 12MM,10609935,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE RT 6-9 EF 12MM,10609935,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD CURVED TI 5.5X30MM,10609936,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD CURVED TI 5.5X30MM,10609936,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT MAIN BODY AFX2 28X100MM,10609937,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,32770.00,9831.00,12714.76,27854.5,,16057.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13763.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12714.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13927.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24577.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16385.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27854.5,,,percent of total billed charges,,,14746.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT MAIN BODY AFX2 28X100MM,10609937,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,32770.00,9831.00,13763.4,27854.5,,16057.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13763.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16529.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13927.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24577.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16385.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24577.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27854.5,,,percent of total billed charges,,,15074.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ILIAC OVATION 22X45MM,10609938,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,18683.00,5604.90,7249.00,15880.55,,9154.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7846.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7249.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7940.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,14012.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15880.55,,,percent of total billed charges,,,8407.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ILIAC OVATION 22X45MM,10609938,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,18683.00,5604.90,7846.86,15880.55,,9154.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7846.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9423.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7940.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,14012.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,14012.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15880.55,,,percent of total billed charges,,,8594.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN EXTERNAL 4X100X20MM BLUE,10609940,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,614.00,184.20,238.23,521.90,,,,,,,,,,,,,,,,,,,,238.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,460.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,307.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,521.90,,,percent of total billed charges,,,276.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN EXTERNAL 4X100X20MM BLUE,10609940,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,614.00,184.20,260.95,521.90,,,,,,,,,,,,,service not payable,,,,,,,309.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,260.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,460.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,307.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,460.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,521.90,,,percent of total billed charges,,,282.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM 10MMX36CM 125DEG,10609941,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM 10MMX36CM 125DEG,10609941,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL PS 10MM 71/75MM,10609942,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL PS 10MM 71/75MM,10609942,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 4MMX150MMX130CM,10609943,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,2431.21,,,percent of total billed charges,,,,,,,,service not payable,1919.79,,,percent of total billed charges,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1967.0,,,percent of total billed charges,,,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,2557.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BALLOON 4MMX80MMX130MM,10609944,CDM,0272,RC,C2623,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,3039.32,,,percent of total billed charges,,,,,,,,service not payable,2399.98,,,percent of total billed charges,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2459.0,,,percent of total billed charges,,,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,3196.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT PIP ST 16MM CONCAVE,10609945,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6213.00,1863.90,2410.64,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2410.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5281.05,,,percent of total billed charges,,,2795.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT PIP ST 16MM CONCAVE,10609945,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6213.00,1863.90,2609.46,5281.05,,3044.37,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2609.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3133.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2640.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4659.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3106.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4659.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5281.05,,,percent of total billed charges,,,2857.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MAXFORCE RT 5 DEG,10609947,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MAXFORCE RT 5 DEG,10609947,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMUR PSN LT SZ9,10609948,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMUR PSN LT SZ9,10609948,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR SZ 11 LT,10609949,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6885.00,2065.50,2671.38,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2671.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5852.25,,,percent of total billed charges,,,3098.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR SZ 11 LT,10609949,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6885.00,2065.50,2891.70,5852.25,,3373.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2891.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3472.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2926.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5163.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3442.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5163.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5852.25,,,percent of total billed charges,,,3167.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR PSN 8-11 13MM L,10609950,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR PSN 8-11 13MM L,10609950,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR 36MM SZ E,10609951,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR 36MM SZ E,10609951,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW 2.7X11MM,10609952,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,518.00,155.40,200.98,440.30,,,,,,,,,,,,,,,,,,,,200.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,388.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,259.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,440.30,,,percent of total billed charges,,,233.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW 2.7X11MM,10609952,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,518.00,155.40,220.15,440.30,,,,,,,,,,,,,service not payable,,,,,,,261.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,220.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,388.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,259.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,388.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,440.30,,,percent of total billed charges,,,238.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLIDESCOPE BFLEX BRONCHO 3.8MM,10609953,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1476.00,442.80,572.69,1254.60,,,,,,,,,,,,,,,,,,,,572.69,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1107.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,738.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1254.60,,,percent of total billed charges,,,664.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDESCOPE BFLEX BRONCHO 3.8MM,10609953,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1476.00,442.80,627.30,1254.60,,,,,,,,,,,,,service not payable,,,,,,,744.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1107.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,738.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1107.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1254.60,,,percent of total billed charges,,,678.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ9 LT,10610024,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ9 LT,10610024,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
VALVE AOR ESP 23MM,10610025,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,16228.00,4868.40,6296.46,13793.80,,7951.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6815.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6296.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6896.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12171.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8114.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13793.80,,,percent of total billed charges,,,7302.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALVE AOR ESP 23MM,10610025,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,16228.00,4868.40,6815.76,13793.80,,7951.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6815.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8185.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6896.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12171.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8114.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12171.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13793.80,,,percent of total billed charges,,,7464.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC PPS SZ 18,10610136,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC PPS SZ 18,10610136,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3.5X107MM 8H,10610137,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,903.00,270.90,350.36,767.55,,,,,,,,,,,,,,,,,,,,350.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.55,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3.5X107MM 8H,10610137,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,903.00,270.90,383.77,767.55,,,,,,,,,,,,,service not payable,,,,,,,455.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,383.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,677.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,451.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,677.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,767.55,,,percent of total billed charges,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT STEM RADIAL 8MM,10610138,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7016.00,2104.80,2722.21,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2722.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5963.60,,,percent of total billed charges,,,3157.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT STEM RADIAL 8MM,10610138,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7016.00,2104.80,2946.72,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3538.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5963.60,,,percent of total billed charges,,,3227.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT HEAD RADIAL 20MM,10610139,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7016.00,2104.80,2722.21,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2722.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5963.60,,,percent of total billed charges,,,3157.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT HEAD RADIAL 20MM,10610139,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7016.00,2104.80,2946.72,5963.60,,3437.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2946.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3538.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2981.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5262.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5262.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5963.60,,,percent of total billed charges,,,3227.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH DIALYSIS 2CUFF LT 62.5CM,10610574,CDM,0272,RC,C1750,HCPCS,,,,,,outpatient,facility,,,1123.00,336.90,477.27,954.55,,694.01,,,percent of total billed charges,,,,,,,,service not payable,548.02,,,percent of total billed charges,,,566.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,477.27,,,percent of total billed charges,,,,,,,,,842.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,561.5,,,percent of total billed charges,,,,,,,,service not payable,842.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,954.55,,,percent of total billed charges,,,516.58,,,percent of total billed charges,,,,,,,,,729.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,729.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 16.5D,10610575,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 16.5D,10610575,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF ULTRASERT 27.0D,10610576,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF ULTRASERT 27.0D,10610576,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR RIGHT SZ 5,10610577,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR RIGHT SZ 5,10610577,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART 10MM RT 3-5CD,10610578,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART 10MM RT 3-5CD,10610578,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM 12/14 SZ10 EXT,10610579,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM 12/14 SZ10 EXT,10610579,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER DUAL ACETAB 46MM G,10610580,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5665.00,1699.50,2198.02,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2198.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4815.25,,,percent of total billed charges,,,2549.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER DUAL ACETAB 46MM G,10610580,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5665.00,1699.50,2379.30,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2857.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4815.25,,,percent of total billed charges,,,2605.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB 58MM G,10610581,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB 58MM G,10610581,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING DM 28X46MM G,10610582,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING DM 28X46MM G,10610582,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PET Exam,10610792,CDM,0404,RC,78815,CPT,,,,,,outpatient,facility,,,7810.00,2343.00,1990.0,6638.5,,2505.91,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 2,505.91 End FormulaCPE Paid in addition to outpatient services",,,,,,,1990.0,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE",other,,"FormulaCPE:  {Units in Service Type} * 1,990.00 End FormulaCPE Paid in addition to outpatient services",3939.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3319.25,,,percent of total billed charges,,,,,,,,,5857.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3905.0,,,percent of total billed charges,,,,,,,,,5857.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6638.5,,,percent of total billed charges,,,3592.60,,,percent of total billed charges,,,,,,,,,3279.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PET Exam,10610792,CDM,0404,RC,78815,CPT,05594,APC,,,,outpatient,facility,,,7810.00,2343.00,1341.65,3212.54,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2942.46,,,fee schedule,,,1341.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",1426.71,,,fee schedule,,,3212.54,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,2899.82,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,1341.65,,,fee schedule,,,1426.71,,,fee schedule,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1341.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",1426.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,,,,,,,1398.74,,,fee schedule,,,,,,,,,1412.66,,,fee schedule,,,,,,,,
PET Exam,10610792,CDM,0404,RC,78815,CPT,290,EAPG,,,,outpatient,facility,,,7810.00,2343.00,1941.11,5004.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5004.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4254.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1941.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1941.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1941.11,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2974.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,3272.24,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ANCHOR PEEK KNTLSS SNGL 4.75MM,10610892,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3520.00,1056.00,1365.76,2992.0,,,,,,,,,,,,,,,,,,,,1365.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2640.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1760.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2992.0,,,percent of total billed charges,,,1584.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR PEEK KNTLSS SNGL 4.75MM,10610892,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3520.00,1056.00,1496.0,2992.0,,,,,,,,,,,,,service not payable,,,,,,,1775.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1496.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2640.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1760.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2640.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2992.0,,,percent of total billed charges,,,1619.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUTURE FORCE FBR 2 BRD,10610894,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,158.00,47.40,61.30,134.30,,,,,,,,,,,,,,,,,,,,61.30,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,118.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.30,,,percent of total billed charges,,,71.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUTURE FORCE FBR 2 BRD,10610894,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,158.00,47.40,67.15,134.30,,,,,,,,,,,,,service not payable,,,,,,,79.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,67.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,118.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,79.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,118.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,134.30,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY HUM MINI TI 40MM  10MM,10610898,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY HUM MINI TI 40MM  10MM,10610898,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING HUMERAL 40MM,10610899,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4099.00,1229.70,1590.41,3484.15,,,,,,,,,,,,,,,,,,,,1590.41,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.15,,,percent of total billed charges,,,1844.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING HUMERAL 40MM,10610899,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4099.00,1229.70,1742.08,3484.15,,,,,,,,,,,,,service not payable,,,,,,,2067.54,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1742.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3074.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2049.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3074.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3484.15,,,percent of total billed charges,,,1885.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE REV SHOULDER 40MM,10610900,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE REV SHOULDER 40MM,10610900,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FIXED NLK 3.5X4.75X20MM,10610901,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FIXED NLK 3.5X4.75X20MM,10610901,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMUR PSN SZ6 L,10610903,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMUR PSN SZ6 L,10610903,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURFACE 10MM RT,10610904,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURFACE 10MM RT,10610904,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP PAT POLY CEM 38MM 9.5MM,10610905,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP PAT POLY CEM 38MM 9.5MM,10610905,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/3 3H 37MM,10610909,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/3 3H 37MM,10610909,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VPC 2.5X26MM,10610910,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VPC 2.5X26MM,10610910,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE VPC 2.5X24MM,10610911,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE VPC 2.5X24MM,10610911,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORTEX LP 2.4X8MM,10610913,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORTEX LP 2.4X8MM,10610913,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert tunneled CV cath w/o port 5 yrs and older,10611183,CDM,0481,RC,36558,CPT,,,,,,outpatient,facility,,,7328.00,2198.40,3370.88,6509.0,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,3696.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5533.0,,,case rate,,,,,,,,,5496.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6509.0,,,case rate,,,,,,,,,5496.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6228.80,,,percent of total billed charges,,,3370.88,,,percent of total billed charges,,,,,,,,,5314.0,,,case rate,,,,,,,,,,,,,,,4700.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert tunneled CV cath w/o port 5 yrs and older,10611183,CDM,0481,RC,36558,CPT,05183,APC,,,,outpatient,facility,,,7328.00,2198.40,2895.15,6932.39,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6349.58,,,fee schedule,,,2895.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3078.72,,,fee schedule,,,6932.39,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,6257.56,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,2895.15,,,fee schedule,,,3078.72,,,fee schedule,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,2895.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3078.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,,,,,,,3018.35,,,fee schedule,,,,,,,,,3048.41,,,fee schedule,,,,,,,,
Insert tunneled CV cath w/o port 5 yrs and older,10611183,CDM,0481,RC,36558,CPT,83,EAPG,,,,outpatient,facility,,,7328.00,2198.40,3082.81,8961.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7617.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3082.81,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3891.74,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,4280.91,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
EVM - PROLONG OUTPT/OFFICE VIS,10611333,CDM,0300,RC,G2212,HCPCS,,,,,,outpatient,facility,,,42.00,12.60,19.32,63.23,,25.96,,,percent of total billed charges,,,,,,,,service not payable,20.5,,,percent of total billed charges,,,63.23,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,40.10,,,fee schedule,,,,,,,,,31.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,47.16,,,fee schedule,,,,,,,,service not payable,31.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,35.70,,,percent of total billed charges,,,19.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
EVM - PROLONG OUTPT/OFFICE VIS,10611333,CDM,0510,RC,99417,CPT,,,,,,outpatient,facility,,,106.00,31.80,28.19,90.10,,65.51,,,percent of total billed charges,,,,,,,,service not payable,51.73,,,percent of total billed charges,,,53.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,53.0,,,fee schedule,,,28.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",,,,,,service not payable,53.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,79.5,,,percent of total billed charges,,,,,,,,service not payable,28.19,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,28.19,,,fee schedule,,,47.70,,,fee schedule,,,,,,,,,90.10,,,percent of total billed charges,,,48.76,,,percent of total billed charges,,,,,,,,,68.90,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,68.90,,,percent of total billed charges,,,53.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
Plasma Apheresis P4 Thaw E7762/Split,10611390,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,205.0,,30.28,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P4 Thaw E7762/Split,10611390,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,49.00,14.70,49.0,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,49.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,49.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Plasma Apheresis P4 Thaw E7762/Split,10611390,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P4 Thaw E7762,10611391,CDM,0390,RC,P9017,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,205.0,,66.13,,,percent of total billed charges,,,,,,,,,52.22,,,percent of total billed charges,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P4 Thaw E7762,10611391,CDM,0390,RC,P9017,HCPCS,09508,APC,,,,outpatient,facility,,,107.00,32.10,77.53,190.50,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,174.48,,,fee schedule,,,77.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.60,,,fee schedule,,,190.50,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,171.95,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,77.53,,,fee schedule,,,84.60,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,77.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",84.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,83.76,,,fee schedule,,,,,,,,
Plasma Apheresis P4 Thaw E7762,10611391,CDM,0390,RC,P9017,HCPCS,2061,EAPG,,,,outpatient,facility,,,107.00,32.10,107.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P3 Thaw E7761/Split,10611393,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,205.0,,30.28,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P3 Thaw E7761/Split,10611393,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,49.00,14.70,49.0,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,49.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,49.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Plasma Apheresis P3 Thaw E7761/Split,10611393,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P3 Thaw E7761,10611394,CDM,0390,RC,P9017,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,205.0,,66.13,,,percent of total billed charges,,,,,,,,,52.22,,,percent of total billed charges,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P3 Thaw E7761,10611394,CDM,0390,RC,P9017,HCPCS,09508,APC,,,,outpatient,facility,,,107.00,32.10,77.53,190.50,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,174.48,,,fee schedule,,,77.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.60,,,fee schedule,,,190.50,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,171.95,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,77.53,,,fee schedule,,,84.60,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,77.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",84.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,83.76,,,fee schedule,,,,,,,,
Plasma Apheresis P3 Thaw E7761,10611394,CDM,0390,RC,P9017,HCPCS,2061,EAPG,,,,outpatient,facility,,,107.00,32.10,107.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P2 Thaw E7760/Split,10611396,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,205.0,,30.28,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P2 Thaw E7760/Split,10611396,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,49.00,14.70,49.0,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,49.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,49.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Plasma Apheresis P2 Thaw E7760/Split,10611396,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P2 Thaw E7760,10611397,CDM,0390,RC,P9017,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,205.0,,66.13,,,percent of total billed charges,,,,,,,,,52.22,,,percent of total billed charges,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P2 Thaw E7760,10611397,CDM,0390,RC,P9017,HCPCS,09508,APC,,,,outpatient,facility,,,107.00,32.10,77.53,190.50,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,174.48,,,fee schedule,,,77.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.60,,,fee schedule,,,190.50,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,171.95,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,77.53,,,fee schedule,,,84.60,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,77.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",84.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,83.76,,,fee schedule,,,,,,,,
Plasma Apheresis P2 Thaw E7760,10611397,CDM,0390,RC,P9017,HCPCS,2061,EAPG,,,,outpatient,facility,,,107.00,32.10,107.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P1 Thaw E7759/Split,10611399,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,205.0,,30.28,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P1 Thaw E7759/Split,10611399,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,49.00,14.70,49.0,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,49.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,49.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Plasma Apheresis P1 Thaw E7759/Split,10611399,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis P1 Thaw E7759,10611400,CDM,0390,RC,P9017,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,205.0,,66.13,,,percent of total billed charges,,,,,,,,,52.22,,,percent of total billed charges,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis P1 Thaw E7759,10611400,CDM,0390,RC,P9017,HCPCS,09508,APC,,,,outpatient,facility,,,107.00,32.10,77.53,190.50,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,174.48,,,fee schedule,,,77.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.60,,,fee schedule,,,190.50,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,171.95,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,77.53,,,fee schedule,,,84.60,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,77.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",84.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,83.76,,,fee schedule,,,,,,,,
Plasma Apheresis P1 Thaw E7759,10611400,CDM,0390,RC,P9017,HCPCS,2061,EAPG,,,,outpatient,facility,,,107.00,32.10,107.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis Thaw E2284,10611403,CDM,0390,RC,P9017,HCPCS,,,,,,outpatient,facility,,,107.00,32.10,45.48,205.0,,66.13,,,percent of total billed charges,,,,,,,,,52.22,,,percent of total billed charges,,,53.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.5,,,percent of total billed charges,,,,,,,,,80.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.95,,,percent of total billed charges,,,49.22,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis Thaw E2284,10611403,CDM,0390,RC,P9017,HCPCS,09508,APC,,,,outpatient,facility,,,107.00,32.10,77.53,190.50,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,174.48,,,fee schedule,,,77.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",84.60,,,fee schedule,,,190.50,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,171.95,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,77.53,,,fee schedule,,,84.60,,,fee schedule,,,,,,,,,82.94,,,fee schedule,,,,,,,,,77.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",84.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,,,,,,,82.94,,,fee schedule,,,,,,,,,83.76,,,fee schedule,,,,,,,,
Plasma Apheresis Thaw E2284,10611403,CDM,0390,RC,P9017,HCPCS,2061,EAPG,,,,outpatient,facility,,,107.00,32.10,107.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,107.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Plasma Apheresis Thaw E2284/Split,10611404,CDM,0390,RC,P9011,HCPCS,,,,,,outpatient,facility,,,49.00,14.70,20.82,205.0,,30.28,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,24.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,36.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,180.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Plasma Apheresis Thaw E2284/Split,10611404,CDM,0390,RC,P9011,HCPCS,09520,APC,,,,outpatient,facility,,,49.00,14.70,49.0,320.47,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,293.53,,,fee schedule,,,49.0,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",142.32,,,fee schedule,,,320.47,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,289.27,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,130.43,,,fee schedule,,,142.32,,,fee schedule,,,,,,,,,139.53,,,fee schedule,,,,,,,,,49.0,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",142.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,,,,,,,139.53,,,fee schedule,,,,,,,,,140.92,,,fee schedule,,,,,,,,
Plasma Apheresis Thaw E2284/Split,10611404,CDM,0390,RC,P9011,HCPCS,2061,EAPG,,,,outpatient,facility,,,49.00,14.70,49.0,516.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,439.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,49.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,389.36,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,428.30,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
INTERBODY 12D 10X10X25MM,10611571,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3738.00,1121.40,1450.34,3177.30,,,,,,,,,,,,,,,,,,,,1450.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3177.30,,,percent of total billed charges,,,1682.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTERBODY 12D 10X10X25MM,10611571,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3738.00,1121.40,1588.65,3177.30,,,,,,,,,,,,,service not payable,,,,,,,1885.45,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1588.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2803.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1869.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2803.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3177.30,,,percent of total billed charges,,,1719.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE CLAV SUP LT 9H 90MM,10611572,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3895.00,1168.50,1511.26,3310.75,,,,,,,,,,,,,,,,,,,,1511.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3310.75,,,percent of total billed charges,,,1752.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE CLAV SUP LT 9H 90MM,10611572,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3895.00,1168.50,1655.38,3310.75,,,,,,,,,,,,,service not payable,,,,,,,1964.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3310.75,,,percent of total billed charges,,,1791.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM G7 ACETAB 36MM 9MM,10611574,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM G7 ACETAB 36MM 9MM,10611574,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE ALLOGRAFT PUROS 1ML,10611575,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,998.00,299.40,387.22,848.30,,,,,,,,,,,,,,,,,,,,387.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,748.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,499.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,848.30,,,percent of total billed charges,,,449.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT BONE ALLOGRAFT PUROS 1ML,10611575,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,998.00,299.40,424.15,848.30,,,,,,,,,,,,,service not payable,,,,,,,503.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,424.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,748.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,499.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,748.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,848.30,,,percent of total billed charges,,,459.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT BONE ALLOGRAFT PUROS 1ML,10611575,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,998.00,299.40,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ5 130D 124X29MM,10611576,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5245.00,1573.50,2035.06,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2035.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4458.25,,,percent of total billed charges,,,2360.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ5 130D 124X29MM,10611576,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5245.00,1573.50,2202.90,4458.25,,2570.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2202.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2645.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2229.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3933.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2622.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3933.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4458.25,,,percent of total billed charges,,,2412.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SFC PSN L 11MM 4-5/CD,10611578,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SFC PSN L 11MM 4-5/CD,10611578,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ4 LT,10611579,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ4 LT,10611579,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH DRYSEAL FLEX 10F 45CM,10611580,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2716.00,814.80,1154.3,2308.60,,1678.49,,,percent of total billed charges,,,,,,,,service not payable,1325.41,,,percent of total billed charges,,,1369.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1154.3,,,percent of total billed charges,,,,,,,,,2037.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1358.0,,,percent of total billed charges,,,,,,,,service not payable,2037.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2308.60,,,percent of total billed charges,,,1249.36,,,percent of total billed charges,,,,,,,,,1765.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1765.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 9X36MMX120CM,10611581,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2557.00,767.10,992.12,2173.45,,,,,,,,,,,,,,,,,,,,992.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1086.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1917.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1278.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2173.45,,,percent of total billed charges,,,1150.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 9X36MMX120CM,10611581,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2557.00,767.10,1086.72,2173.45,,,,,,,,,,,,,service not payable,,,,,,,1289.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1086.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1917.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1278.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1917.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2173.45,,,percent of total billed charges,,,1176.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 6F 9X60MMX80CM,10611582,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 6F 9X60MMX80CM,10611582,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT BILIARY 6F 9X80MMX80CM,10611583,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,1968.00,590.40,763.58,1672.8,,,,,,,,,,,,,,,,,,,,763.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1672.8,,,percent of total billed charges,,,885.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT BILIARY 6F 9X80MMX80CM,10611583,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,1968.00,590.40,836.40,1672.8,,,,,,,,,,,,,service not payable,,,,,,,992.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1672.8,,,percent of total billed charges,,,905.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 6X40MMX135CM,10611584,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 6X40MMX135CM,10611584,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 7X40MMX135CM,10611585,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 7X40MMX135CM,10611585,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 6X60MMX135CM,10611586,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 6X60MMX135CM,10611586,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 7X80MMX135CM,10611587,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 7X80MMX135CM,10611587,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VASC 5F 6X100MMX135CM,10611588,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VASC 5F 6X100MMX135CM,10611588,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THD 6.5X85MM,10611592,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1107.00,332.10,429.52,940.95,,,,,,,,,,,,,,,,,,,,429.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,830.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,940.95,,,percent of total billed charges,,,498.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THD 6.5X85MM,10611592,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1107.00,332.10,470.47,940.95,,,,,,,,,,,,,service not payable,,,,,,,558.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,470.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,830.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,553.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,830.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,940.95,,,percent of total billed charges,,,509.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN COMP 6.0X50MM,10611593,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4841.00,1452.30,1878.31,4114.85,,,,,,,,,,,,,,,,,,,,1878.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2057.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3630.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2420.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4114.85,,,percent of total billed charges,,,2178.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN COMP 6.0X50MM,10611593,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4841.00,1452.30,2057.42,4114.85,,,,,,,,,,,,,service not payable,,,,,,,2441.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2057.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3630.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2420.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3630.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4114.85,,,percent of total billed charges,,,2226.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
G-WIRE COMP THD 2.8X20X200MM,10611594,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,470.00,141.00,199.75,399.5,,290.46,,,percent of total billed charges,,,,,,,,service not payable,229.36,,,percent of total billed charges,,,237.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,199.75,,,percent of total billed charges,,,,,,,,,352.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,235.0,,,percent of total billed charges,,,,,,,,service not payable,352.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,399.5,,,percent of total billed charges,,,216.20,,,percent of total billed charges,,,,,,,,,305.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,305.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE TI CAN COMP 4X54,10611595,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2745.00,823.50,1065.06,2333.25,,,,,,,,,,,,,,,,,,,,1065.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2333.25,,,percent of total billed charges,,,1235.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE TI CAN COMP 4X54,10611595,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2745.00,823.50,1166.62,2333.25,,,,,,,,,,,,,service not payable,,,,,,,1384.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1166.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2058.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1372.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2058.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2333.25,,,percent of total billed charges,,,1262.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN HEADLS 3X40MM,10611596,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2708.00,812.40,1050.70,2301.80,,,,,,,,,,,,,,,,,,,,1050.70,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2301.80,,,percent of total billed charges,,,1218.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN HEADLS 3X40MM,10611596,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2708.00,812.40,1150.90,2301.80,,,,,,,,,,,,,service not payable,,,,,,,1365.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1150.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2031.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1354.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2031.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2301.80,,,percent of total billed charges,,,1245.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURF 13MM RT 6-7 EF,10611597,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURF 13MM RT 6-7 EF,10611597,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMUR PSN SZ7 R,10611598,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11227.00,3368.10,4356.08,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4356.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9542.95,,,percent of total billed charges,,,5052.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMUR PSN SZ7 R,10611598,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11227.00,3368.10,4715.34,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5662.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9542.95,,,percent of total billed charges,,,5164.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE ATTUNE REV PC TIB 29MM,10611599,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,12995.00,3898.50,5042.06,11045.75,,6367.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5457.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5042.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5522.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9746.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6497.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11045.75,,,percent of total billed charges,,,5847.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE ATTUNE REV PC TIB 29MM,10611599,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,12995.00,3898.50,5457.90,11045.75,,6367.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5457.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,6554.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,5522.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,9746.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,6497.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9746.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,11045.75,,,percent of total billed charges,,,5977.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT P-FORM KNEE REV SZ5 8MM,10611600,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,10543.00,3162.90,4090.68,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4090.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8961.55,,,percent of total billed charges,,,4744.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT P-FORM KNEE REV SZ5 8MM,10611600,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,10543.00,3162.90,4428.06,8961.55,,5166.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4428.06,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5317.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4480.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7907.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5271.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7907.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8961.55,,,percent of total billed charges,,,4849.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPLANT VALVE GLAUCOMA FLX PED,10612082,CDM,0278,RC,C1783,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPLANT VALVE GLAUCOMA FLX PED,10612082,CDM,0278,RC,C1783,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWIVELK C 4.75X19.1MM,10612083,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3070.00,921.00,1191.16,2609.5,,,,,,,,,,,,,,,,,,,,1191.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2302.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1535.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2609.5,,,percent of total billed charges,,,1381.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWIVELK C 4.75X19.1MM,10612083,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3070.00,921.00,1304.75,2609.5,,,,,,,,,,,,,service not payable,,,,,,,1548.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1304.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2302.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1535.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2302.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2609.5,,,percent of total billed charges,,,1412.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NAT 125D 11.5MMX38CM,10612086,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NAT 125D 11.5MMX38CM,10612086,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT HALF RM EF 5MM,10612087,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT HALF RM EF 5MM,10612087,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT RT LATERAL 5MM,10612088,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT RT LATERAL 5MM,10612088,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM PERS RT SZ 7 PLUS,10612089,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24997.00,7499.10,9698.84,21247.45,,12248.53,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10498.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9698.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10623.72,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18747.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12498.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21247.45,,,percent of total billed charges,,,11248.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM PERS RT SZ 7 PLUS,10612089,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24997.00,7499.10,10498.74,21247.45,,12248.53,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10498.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12608.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10623.72,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18747.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12498.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18747.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,21247.45,,,percent of total billed charges,,,11498.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT POST STBLZD 63/67X12MM,10612090,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT POST STBLZD 63/67X12MM,10612090,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WEDGE PSN FEM DIST SZ 7 10MM,10612091,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEDGE PSN FEM DIST SZ 7 10MM,10612091,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 1/3 THREAD 4.0X32MM,10612092,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 1/3 THREAD 4.0X32MM,10612092,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 1/3 THREAD 4.0X42MM,10612093,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 1/3 THREAD 4.0X42MM,10612093,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE BONE 1.6MMX9IN,10612094,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,271.00,81.30,105.15,230.35,,,,,,,,,,,,,,,,,,,,105.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,203.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,135.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.35,,,percent of total billed charges,,,121.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE BONE 1.6MMX9IN,10612094,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,271.00,81.30,115.18,230.35,,,,,,,,,,,,,service not payable,,,,,,,136.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,115.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,203.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,135.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,203.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,230.35,,,percent of total billed charges,,,124.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL 10MM X 36CM,10612095,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4816.00,1444.80,1868.61,4093.60,,,,,,,,,,,,,,,,,,,,1868.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3612.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2408.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4093.60,,,percent of total billed charges,,,2167.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL 10MM X 36CM,10612095,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4816.00,1444.80,2046.8,4093.60,,,,,,,,,,,,,service not payable,,,,,,,2429.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2046.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3612.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2408.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3612.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4093.60,,,percent of total billed charges,,,2215.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLY 3.5 X 10MM,10612842,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2181.00,654.30,846.23,1853.85,,,,,,,,,,,,,,,,,,,,846.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.85,,,percent of total billed charges,,,981.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLY 3.5 X 10MM,10612842,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2181.00,654.30,926.92,1853.85,,,,,,,,,,,,,service not payable,,,,,,,1100.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1853.85,,,percent of total billed charges,,,1003.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLY 3.5 X 12MM,10612843,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2181.00,654.30,846.23,1853.85,,,,,,,,,,,,,,,,,,,,846.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.85,,,percent of total billed charges,,,981.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLY 3.5 X 12MM,10612843,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2181.00,654.30,926.92,1853.85,,,,,,,,,,,,,service not payable,,,,,,,1100.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1853.85,,,percent of total billed charges,,,1003.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD VIRAGE CVD TI 3.5 X 25MM,10612844,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD VIRAGE CVD TI 3.5 X 25MM,10612844,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SET SCREW TOP CLOSURE STD,10612845,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SET SCREW TOP CLOSURE STD,10612845,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW INTERFACE 6X20MM,10612850,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW INTERFACE 6X20MM,10612850,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP 4X50MM,10612851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP 4X50MM,10612851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MAXFORCE L 5-5 RT,10612852,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MAXFORCE L 5-5 RT,10612852,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 1/3THD 4.0X38MM,10612853,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 1/3THD 4.0X38MM,10612853,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT URETERAL 4.8FX30CM,10612854,CDM,0278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT URETERAL 4.8FX30CM,10612854,CDM,0278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD TI ALLOY CRV 120MM,10612855,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,356.00,106.80,138.13,302.60,,,,,,,,,,,,,,,,,,,,138.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.60,,,percent of total billed charges,,,160.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD TI ALLOY CRV 120MM,10612855,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,356.00,106.80,151.30,302.60,,,,,,,,,,,,,service not payable,,,,,,,179.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,151.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,267.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,178.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,267.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,302.60,,,percent of total billed charges,,,163.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PUTTY WITH CHIPS 10ML,10612856,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4125.00,1237.50,1600.5,3506.25,,,,,,,,,,,,,,,,,,,,1600.5,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1753.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3093.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2062.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3506.25,,,percent of total billed charges,,,1856.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PUTTY WITH CHIPS 10ML,10612856,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4125.00,1237.50,1753.12,3506.25,,,,,,,,,,,,,service not payable,,,,,,,2080.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1753.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3093.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2062.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3093.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3506.25,,,percent of total billed charges,,,1897.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTI SUR VE L 8-11 14MM,10612857,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTI SUR VE L 8-11 14MM,10612857,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL STEM FREE 42X15MM,10612858,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL STEM FREE 42X15MM,10612858,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN CENTRAL SIDUS 3.2MM,10612859,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,132.00,39.60,51.22,112.2,,,,,,,,,,,,,,,,,,,,51.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,99.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.2,,,percent of total billed charges,,,59.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN CENTRAL SIDUS 3.2MM,10612859,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,132.00,39.60,56.10,112.2,,,,,,,,,,,,,service not payable,,,,,,,66.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,99.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,66.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,99.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,112.2,,,percent of total billed charges,,,60.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT LPS XL SZ F 5-7 20MM,10612861,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT LPS XL SZ F 5-7 20MM,10612861,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT INTERGRO DBM FIBERS 10ML,10612862,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,5665.00,1699.50,2198.02,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2198.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4815.25,,,percent of total billed charges,,,2549.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT INTERGRO DBM FIBERS 10ML,10612862,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,5665.00,1699.50,2379.30,4815.25,,2775.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2379.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2857.43,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2407.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4248.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2832.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4248.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4815.25,,,percent of total billed charges,,,2605.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT INTERGRO DBM FIBERS 10ML,10612862,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,5665.00,1699.50,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Cytomegalovirus (CMV) by Qualitative PCR Saliva (2,10613145,CDM,0300,RC,87496,CPT,,,,,,outpatient,facility,,,149.00,44.70,33.34,149.0,,149.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,34.39,,,fee schedule,,,111.28,,,fee schedule,,,73.18,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,72.64,,,fee schedule,,,33.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",35.08,,,fee schedule,,,79.30,,,fee schedule,,,,,,,,,34.39,,,fee schedule,,,,,,,,,45.08,,,fee schedule,,,71.58,,,fee schedule,,,111.75,,,percent of total billed charges,,,34.39,,,fee schedule,,,33.34,,,fee schedule,,,35.08,,,fee schedule,,,53.01,,,fee schedule,,,34.39,,,fee schedule,,,111.75,,,percent of total billed charges,,,,,,,,,35.08,,,fee schedule,,,,,,,,,126.65,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,38.60,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.04,,,fee schedule,,,34.39,,,fee schedule,,,,,,,,,34.73,,,fee schedule,,,,,,,,
Cytomegalovirus (CMV) by Qualitative PCR Saliva (2,10613145,CDM,0300,RC,87496,CPT,397,EAPG,,,,outpatient,facility,,,149.00,44.70,50.59,116.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,99.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,50.59,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,74.40,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,81.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
IMPL SYS MPFL TIGHTROPE 3.9MM,10613262,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6541.00,1962.30,2537.91,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2537.91,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5559.85,,,percent of total billed charges,,,2943.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPL SYS MPFL TIGHTROPE 3.9MM,10613262,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6541.00,1962.30,2747.22,5559.85,,3205.09,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2747.22,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3299.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2779.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4905.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3270.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4905.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5559.85,,,percent of total billed charges,,,3008.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT ENDURANT II 16X16X146MM,10613263,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,17938.00,5381.40,6959.94,15247.30,,8789.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7533.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6959.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7623.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13453.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8969.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15247.30,,,percent of total billed charges,,,8072.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT ENDURANT II 16X16X146MM,10613263,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,17938.00,5381.40,7533.96,15247.30,,8789.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7533.96,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9047.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7623.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13453.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8969.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13453.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15247.30,,,percent of total billed charges,,,8251.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SPACER PEEK 8X20X4DEG,10613264,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7868.00,2360.40,3052.78,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3052.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6687.80,,,percent of total billed charges,,,3540.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SPACER PEEK 8X20X4DEG,10613264,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7868.00,2360.40,3304.56,6687.80,,3855.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3304.56,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3968.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5901.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3934.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5901.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6687.80,,,percent of total billed charges,,,3619.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL ANKLE 12X210MM,10613267,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,7582.00,2274.60,2941.82,6444.70,,3715.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3184.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2941.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3222.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5686.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3791.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6444.70,,,percent of total billed charges,,,3411.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL ANKLE 12X210MM,10613267,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,7582.00,2274.60,3184.44,6444.70,,3715.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3184.44,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3824.36,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3222.35,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5686.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3791.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5686.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6444.70,,,percent of total billed charges,,,3487.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X28MM,10613268,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X28MM,10613268,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X34MM,10613269,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X34MM,10613269,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X80MM,10613270,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X80MM,10613270,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X110MM,10613271,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X110MM,10613271,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE PHOENIX 3.2X320MM,10613272,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE ARCOS SZ A 50MM,10613274,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21751.00,6525.30,8439.39,18488.35,,10657.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9135.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8439.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9244.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16313.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10875.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18488.35,,,percent of total billed charges,,,9787.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE ARCOS SZ A 50MM,10613274,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21751.00,6525.30,9135.42,18488.35,,10657.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9135.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10971.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9244.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16313.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10875.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16313.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18488.35,,,percent of total billed charges,,,10005.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FIXED ST OZARK 4.0X16MM,10613275,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FIXED ST OZARK 4.0X16MM,10613275,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VARI ST OZARK 4.0X16MM,10613276,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VARI ST OZARK 4.0X16MM,10613276,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 45X28MM,10613277,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 45X28MM,10613277,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 6.6X39.6X132MM,10613278,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 6.6X39.6X132MM,10613278,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE TIBIA DIST MEDL RT,10613279,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1241.00,372.30,481.51,1054.85,,,,,,,,,,,,,,,,,,,,481.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,930.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,620.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1054.85,,,percent of total billed charges,,,558.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE TIBIA DIST MEDL RT,10613279,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1241.00,372.30,527.42,1054.85,,,,,,,,,,,,,service not payable,,,,,,,625.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,527.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,930.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,620.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,930.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1054.85,,,percent of total billed charges,,,570.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ11 M/L,10613280,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ11 M/L,10613280,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLX DELTA 40MM,10613281,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLX DELTA 40MM,10613281,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV 3MM 11X135MM,10613282,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV 3MM 11X135MM,10613282,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART 12MM RT,10613283,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART 12MM RT,10613283,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ASSY HUM C/M ELBOW SM 6IN REG,10613284,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASSY HUM C/M ELBOW SM 6IN REG,10613284,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ASSY ULNAR C/M ELBOW RT 4.5IN,10613285,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16063.00,4818.90,6232.44,13653.55,,7870.87,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6746.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6232.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6826.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12047.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8031.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13653.55,,,percent of total billed charges,,,7228.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASSY ULNAR C/M ELBOW RT 4.5IN,10613285,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16063.00,4818.90,6746.46,13653.55,,7870.87,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6746.46,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8102.18,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6826.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12047.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8031.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12047.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13653.55,,,percent of total billed charges,,,7388.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X42MM,10613286,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X42MM,10613286,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM CCR REVIS LT SZ 5,10613287,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,23357.00,7007.10,9062.52,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9062.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19853.45,,,percent of total billed charges,,,10510.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM CCR REVIS LT SZ 5,10613287,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,23357.00,7007.10,9809.94,19853.45,,11444.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9809.94,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11781.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9926.73,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,17517.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,11678.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,17517.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,19853.45,,,percent of total billed charges,,,10744.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM POST SZ 5MM,10613288,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM POST SZ 5MM,10613288,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
FEMORAL DISTAL AUGMNT 5 5 5MM,10613289,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FEMORAL DISTAL AUGMNT 5 5 5MM,10613289,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE TIB PERS REV SZ MED,10613290,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16801.00,5040.30,6518.79,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6518.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14280.85,,,percent of total billed charges,,,7560.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE TIB PERS REV SZ MED,10613290,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16801.00,5040.30,7056.42,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8474.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14280.85,,,percent of total billed charges,,,7728.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV OFFSET 15X135MM,10613291,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV OFFSET 15X135MM,10613291,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF 3-5 CD LT 16MM,10613292,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF 3-5 CD LT 16MM,10613292,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 4H 60MM SZG,10613293,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 4H 60MM SZG,10613293,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ 15 12/14 15X129MM,10613294,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ 15 12/14 15X129MM,10613294,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANCELLOUS 3.5X65MM,10613295,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,861.00,258.30,334.07,731.85,,,,,,,,,,,,,,,,,,,,334.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.85,,,percent of total billed charges,,,387.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANCELLOUS 3.5X65MM,10613295,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,861.00,258.30,365.93,731.85,,,,,,,,,,,,,service not payable,,,,,,,434.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,645.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,396.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INTERBODY 8D 7X11X30MM,10613296,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INTERBODY 8D 7X11X30MM,10613296,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEG WRST LKING 2X18MM,10613297,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,414.00,124.20,160.63,351.90,,,,,,,,,,,,,,,,,,,,160.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.90,,,percent of total billed charges,,,186.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEG WRST LKING 2X18MM,10613297,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,414.00,124.20,175.95,351.90,,,,,,,,,,,,,service not payable,,,,,,,208.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,175.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,310.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,207.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,310.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,351.90,,,percent of total billed charges,,,190.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEG FULL THREAD 15X2.5MM,10613299,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,414.00,124.20,160.63,351.90,,,,,,,,,,,,,,,,,,,,160.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.90,,,percent of total billed charges,,,186.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEG FULL THREAD 15X2.5MM,10613299,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,414.00,124.20,175.95,351.90,,,,,,,,,,,,,service not payable,,,,,,,208.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,175.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,310.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,207.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,310.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,351.90,,,percent of total billed charges,,,190.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PEG WRST PT THRD 2X10M,10613300,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,414.00,124.20,160.63,351.90,,,,,,,,,,,,,,,,,,,,160.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.90,,,percent of total billed charges,,,186.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PEG WRST PT THRD 2X10M,10613300,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,414.00,124.20,175.95,351.90,,,,,,,,,,,,,service not payable,,,,,,,208.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,175.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,310.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,207.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,310.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,351.90,,,percent of total billed charges,,,190.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM LAT ECO SZ12 140MM T1,10613302,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM LAT ECO SZ12 140MM T1,10613302,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM LAT ECO SZ14 150MM T1,10613303,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM LAT ECO SZ14 150MM T1,10613303,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NARROW RT SZ 7,10613304,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NARROW RT SZ 7,10613304,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART PSN VIV CD 6-7 11MM R,10613305,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART PSN VIV CD 6-7 11MM R,10613305,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 LONGEVITY 36MM SZF,10613306,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 LONGEVITY 36MM SZF,10613306,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUMERAL REMEDY MEDIUM,10613307,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9016.00,2704.80,3498.21,7663.60,,4417.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3786.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3498.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3831.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.60,,,percent of total billed charges,,,4057.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUMERAL REMEDY MEDIUM,10613307,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9016.00,2704.80,3786.72,7663.60,,4417.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3786.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4547.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3831.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6762.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7663.60,,,percent of total billed charges,,,4147.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUMERAL REMEDY 50MM,10613308,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9016.00,2704.80,3498.21,7663.60,,4417.84,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3786.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3498.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3831.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4508.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.60,,,percent of total billed charges,,,4057.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUMERAL REMEDY 50MM,10613308,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9016.00,2704.80,3786.72,7663.60,,4417.84,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3786.72,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4547.67,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3831.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4508.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6762.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7663.60,,,percent of total billed charges,,,4147.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR MM 60MM,10613309,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR MM 60MM,10613309,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR MM 40X60MM,10613310,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR MM 40X60MM,10613310,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12/14 TPR 40MM -3.5MM,10613311,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12/14 TPR 40MM -3.5MM,10613311,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CORT ST 4.5X95MM,10613840,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,223.00,66.90,86.52,189.55,,,,,,,,,,,,,,,,,,,,86.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.55,,,percent of total billed charges,,,100.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CORT ST 4.5X95MM,10613840,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,223.00,66.90,94.77,189.55,,,,,,,,,,,,,service not payable,,,,,,,112.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,94.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,167.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,111.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,167.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,189.55,,,percent of total billed charges,,,102.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE KIRSCH W/TRCR 2.5MM,10613843,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,165.00,49.50,64.02,140.25,,,,,,,,,,,,,,,,,,,,64.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE KIRSCH W/TRCR 2.5MM,10613843,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,165.00,49.50,70.12,140.25,,,,,,,,,,,,,service not payable,,,,,,,83.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,70.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,123.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,82.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,123.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,140.25,,,percent of total billed charges,,,75.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL AFIXS PRX HUM L 10X200MM,10613844,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4603.00,1380.90,1785.96,3912.55,,,,,,,,,,,,,,,,,,,,1785.96,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1956.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3452.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2301.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3912.55,,,percent of total billed charges,,,2071.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL AFIXS PRX HUM L 10X200MM,10613844,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4603.00,1380.90,1956.27,3912.55,,,,,,,,,,,,,service not payable,,,,,,,2321.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1956.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3452.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2301.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3452.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3912.55,,,percent of total billed charges,,,2117.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS BLNT 4X46MM,10613845,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS BLNT 4X46MM,10613845,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS BLNT 4X48MM,10613846,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS BLNT 4X48MM,10613846,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS BLNT 4X40MM,10613847,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS BLNT 4X40MM,10613847,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS CORT 4X24M,10613848,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS CORT 4X24M,10613848,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE AFFIXUS HUM BL NS ST,10613849,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1476.00,442.80,627.30,1254.60,,912.17,,,percent of total billed charges,,,,,,,,service not payable,720.29,,,percent of total billed charges,,,744.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,,,,,,,1107.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,1107.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1254.60,,,percent of total billed charges,,,678.96,,,percent of total billed charges,,,,,,,,,959.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,959.40,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE MD 2.7X16MM,10613850,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,763.00,228.90,296.04,648.55,,,,,,,,,,,,,,,,,,,,296.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,572.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,381.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.55,,,percent of total billed charges,,,343.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE MD 2.7X16MM,10613850,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,763.00,228.90,324.27,648.55,,,,,,,,,,,,,service not payable,,,,,,,384.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,324.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,572.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,381.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,572.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,648.55,,,percent of total billed charges,,,350.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ULNAR DVR BILATERAL,10613851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2931.00,879.30,1137.23,2491.35,,,,,,,,,,,,,,,,,,,,1137.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1245.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2198.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1465.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2491.35,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ULNAR DVR BILATERAL,10613851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2931.00,879.30,1245.68,2491.35,,,,,,,,,,,,,service not payable,,,,,,,1478.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1245.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2198.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1465.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2198.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2491.35,,,percent of total billed charges,,,1348.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PERI-LOCKING 3.5X32MM,10613852,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERI-LOCKING 3.5X32MM,10613852,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PERI-LOCKING 3.5X52MM,10613853,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PERI-LOCKING 3.5X52MM,10613853,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCKNG DIST M TIB 10H RT,10613854,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4410.00,1323.00,1711.08,3748.5,,,,,,,,,,,,,,,,,,,,1711.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1874.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3748.5,,,percent of total billed charges,,,1984.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCKNG DIST M TIB 10H RT,10613854,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4410.00,1323.00,1874.25,3748.5,,,,,,,,,,,,,service not payable,,,,,,,2224.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1874.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3748.5,,,percent of total billed charges,,,2028.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH SPECTRUM 4F 5CM PEDI,10613855,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,675.00,202.50,286.88,573.75,,417.15,,,percent of total billed charges,,,,,,,,service not payable,329.40,,,percent of total billed charges,,,340.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,286.88,,,percent of total billed charges,,,,,,,,,506.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,506.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,573.75,,,percent of total billed charges,,,310.5,,,percent of total billed charges,,,,,,,,,438.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,438.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SET CATH SPECTRUM 4F 12CM PEDI,10613856,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,675.00,202.50,286.88,573.75,,417.15,,,percent of total billed charges,,,,,,,,service not payable,329.40,,,percent of total billed charges,,,340.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,286.88,,,percent of total billed charges,,,,,,,,,506.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,506.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,573.75,,,percent of total billed charges,,,310.5,,,percent of total billed charges,,,,,,,,,438.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,438.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOID MOD 4 PEG SZ 3,10613857,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOID MOD 4 PEG SZ 3,10613857,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR WIDE RT 28X56MM,10613858,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3049.00,914.70,1183.01,2591.65,,,,,,,,,,,,,,,,,,,,1183.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1295.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.65,,,percent of total billed charges,,,1372.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR WIDE RT 28X56MM,10613858,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3049.00,914.70,1295.82,2591.65,,,,,,,,,,,,,service not payable,,,,,,,1537.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1295.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2591.65,,,percent of total billed charges,,,1402.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLOCK 22X2.7MM,10613859,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,320.00,96.00,124.16,272.0,,,,,,,,,,,,,,,,,,,,124.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.0,,,percent of total billed charges,,,144.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLOCK 22X2.7MM,10613859,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,320.00,96.00,136.0,272.0,,,,,,,,,,,,,service not payable,,,,,,,161.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,136.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,240.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,160.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,240.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,272.0,,,percent of total billed charges,,,147.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCKG 2.7X14MM,10613860,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,763.00,228.90,296.04,648.55,,,,,,,,,,,,,,,,,,,,296.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,572.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,381.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.55,,,percent of total billed charges,,,343.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCKG 2.7X14MM,10613860,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,763.00,228.90,324.27,648.55,,,,,,,,,,,,,service not payable,,,,,,,384.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,324.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,572.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,381.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,572.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,648.55,,,percent of total billed charges,,,350.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X56MM,10613861,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X56MM,10613861,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X24MM,10613862,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X24MM,10613862,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HUM PTC LONG FLEX SZ6B,10613863,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HUM PTC LONG FLEX SZ6B,10613863,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS TORIC II 2.25 18.5,10613864,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC II 2.25 18.5,10613864,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLY 3.5 X 14MM,10613865,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2181.00,654.30,846.23,1853.85,,,,,,,,,,,,,,,,,,,,846.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.85,,,percent of total billed charges,,,981.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLY 3.5 X 14MM,10613865,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2181.00,654.30,926.92,1853.85,,,,,,,,,,,,,service not payable,,,,,,,1100.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1853.85,,,percent of total billed charges,,,1003.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLY 4.5 X 20MM,10613866,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2181.00,654.30,846.23,1853.85,,,,,,,,,,,,,,,,,,,,846.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.85,,,percent of total billed charges,,,981.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLY 4.5 X 20MM,10613866,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2181.00,654.30,926.92,1853.85,,,,,,,,,,,,,service not payable,,,,,,,1100.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1853.85,,,percent of total billed charges,,,1003.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE POLY 4.5 X 25MM,10613867,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2181.00,654.30,846.23,1853.85,,,,,,,,,,,,,,,,,,,,846.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.85,,,percent of total billed charges,,,981.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE POLY 4.5 X 25MM,10613867,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2181.00,654.30,926.92,1853.85,,,,,,,,,,,,,service not payable,,,,,,,1100.10,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,926.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1635.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1090.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1635.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1853.85,,,percent of total billed charges,,,1003.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD VIRAGE CVD TI 3.5 X 100MM,10613868,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,410.00,123.00,159.08,348.5,,,,,,,,,,,,,,,,,,,,159.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD VIRAGE CVD TI 3.5 X 100MM,10613868,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,,,,,,,,,,,,service not payable,,,,,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PUTTY WITH CHIPS 5ML,10613869,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,3205.00,961.50,1243.54,2724.25,,,,,,,,,,,,,,,,,,,,1243.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1362.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2403.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1602.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2724.25,,,percent of total billed charges,,,1442.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PUTTY WITH CHIPS 5ML,10613869,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,3205.00,961.50,1362.12,2724.25,,,,,,,,,,,,,service not payable,,,,,,,1616.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1362.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2403.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1602.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2403.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2724.25,,,percent of total billed charges,,,1474.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PUTTY WITH CHIPS 5ML,10613869,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,3205.00,961.50,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT FT 5.5X55MM,10613871,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT FT 5.5X55MM,10613871,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE16MM LONG 6.5X85MM,10613872,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1307.00,392.10,507.12,1110.95,,,,,,,,,,,,,,,,,,,,507.12,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,980.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,653.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1110.95,,,percent of total billed charges,,,588.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE16MM LONG 6.5X85MM,10613872,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1307.00,392.10,555.48,1110.95,,,,,,,,,,,,,service not payable,,,,,,,659.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,555.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,980.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,653.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,980.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1110.95,,,percent of total billed charges,,,601.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PIN GUIDE TIP DRILL 2.8X300MM,10613873,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE TIP DRILL 2.8X300MM,10613873,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH SYN DYN MALL MD 90X90X3MM,10613874,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,9147.00,2744.10,3549.04,7774.95,,4482.03,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3841.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3549.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3887.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6860.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4573.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7774.95,,,percent of total billed charges,,,4116.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH SYN DYN MALL MD 90X90X3MM,10613874,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,9147.00,2744.10,3841.74,7774.95,,4482.03,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3841.74,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4613.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3887.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6860.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4573.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6860.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7774.95,,,percent of total billed charges,,,4207.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MATRIX AMNION THICK 3 X 8CM,10613876,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,14425.00,4327.50,5596.90,12261.25,,7068.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6058.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5596.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6130.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10818.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7212.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12261.25,,,percent of total billed charges,,,6491.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MATRIX AMNION THICK 3 X 8CM,10613876,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,14425.00,4327.50,6058.5,12261.25,,7068.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6058.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7275.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6130.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,10818.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7212.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10818.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12261.25,,,percent of total billed charges,,,6635.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cont Inhalation Tx w/Aerosol Medication-Subsequent,10614636,CDM,0410,RC,94645,CPT,,,,,,outpatient,facility,,,274.00,82.20,116.45,233.0,,169.33,,,percent of total billed charges,,,,,,,,service not payable,133.71,,,percent of total billed charges,,,138.21,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,116.45,,,percent of total billed charges,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,137.0,,,percent of total billed charges,,,,,,,,service not payable,205.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,232.90,,,percent of total billed charges,,,126.04,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,service not payable,,,,,,,205.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cont Inhalation Tx w/Aerosol Medication-Subsequent,10614636,CDM,0410,RC,94645,CPT,412,EAPG,,,,outpatient,facility,,,274.00,82.20,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
First 60 minutes - Car Seat Study Charges (RT),10616923,CDM,0410,RC,94780,CPT,,,,,,outpatient,facility,,,318.00,95.40,135.15,270.30,,196.52,,,percent of total billed charges,,,,,,,,,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.15,,,percent of total billed charges,,,,,,,,,238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,159.0,,,percent of total billed charges,,,,,,,,,238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,,,,,,,,205.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
First 60 minutes - Car Seat Study Charges (RT),10616923,CDM,0410,RC,94780,CPT,05732,APC,,,,outpatient,facility,,,318.00,95.40,36.11,86.44,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,79.18,,,fee schedule,,,36.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",38.39,,,fee schedule,,,86.44,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,78.03,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,36.11,,,fee schedule,,,38.39,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,,,,,,,36.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",38.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,37.64,,,fee schedule,,,,,,,,,38.01,,,fee schedule,,,,,,,,
First 60 minutes - Car Seat Study Charges (RT),10616923,CDM,0410,RC,94780,CPT,412,EAPG,,,,outpatient,facility,,,318.00,95.40,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Additional 90 Minutes - Car Seat Study Charges (RT,10616924,CDM,0410,RC,94781,CPT,,,,,,outpatient,facility,,,99.00,29.70,42.08,233.0,,61.18,,,percent of total billed charges,,,,,,,,service not payable,48.31,,,percent of total billed charges,,,49.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.08,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,74.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,service not payable,,,,,,,205.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Additional 90 Minutes - Car Seat Study Charges (RT,10616924,CDM,0410,RC,94781,CPT,412,EAPG,,,,outpatient,facility,,,99.00,29.70,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Additional 60 Minutes - Car Seat Study Charges (RT,10616925,CDM,0410,RC,94781,CPT,,,,,,outpatient,facility,,,66.00,19.80,28.05,233.0,,40.79,,,percent of total billed charges,,,,,,,,service not payable,32.21,,,percent of total billed charges,,,33.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,service not payable,,,,,,,205.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Additional 60 Minutes - Car Seat Study Charges (RT,10616925,CDM,0410,RC,94781,CPT,412,EAPG,,,,outpatient,facility,,,66.00,19.80,66.0,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,66.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,66.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Additional 30 Minutes - Car Seat Study Charges (RT,10616926,CDM,0410,RC,94781,CPT,,,,,,outpatient,facility,,,33.00,9.90,14.03,233.0,,20.39,,,percent of total billed charges,,,,,,,,service not payable,16.10,,,percent of total billed charges,,,16.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,service not payable,24.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,233.0,,,per diem,,,,,,,,service not payable,,,,,,,205.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Additional 30 Minutes - Car Seat Study Charges (RT,10616926,CDM,0410,RC,94781,CPT,412,EAPG,,,,outpatient,facility,,,33.00,9.90,33.0,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
First 60 minutes - Newborn Car Seat Study Charges(,10616935,CDM,0460,RC,94780,CPT,,,,,,outpatient,facility,,,318.00,95.40,135.15,983.0,,196.52,,,percent of total billed charges,,,,,,,,,155.18,,,percent of total billed charges,,,160.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.15,,,percent of total billed charges,,,,,,,,,238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,159.0,,,percent of total billed charges,,,,,,,,,238.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,270.30,,,percent of total billed charges,,,146.28,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,,,,,,,,865.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
First 60 minutes - Newborn Car Seat Study Charges(,10616935,CDM,0460,RC,94780,CPT,05732,APC,,,,outpatient,facility,,,318.00,95.40,36.11,86.44,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,79.18,,,fee schedule,,,36.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",38.39,,,fee schedule,,,86.44,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,78.03,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,36.11,,,fee schedule,,,38.39,,,fee schedule,,,,,,,,,37.64,,,fee schedule,,,,,,,,,36.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",38.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.64,,,fee schedule,,,,,,,,,,,,,,,37.64,,,fee schedule,,,,,,,,,38.01,,,fee schedule,,,,,,,,
First 60 minutes - Newborn Car Seat Study Charges(,10616935,CDM,0460,RC,94780,CPT,412,EAPG,,,,outpatient,facility,,,318.00,95.40,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Additional 90 Minutes - Newborn Car Seat Study Cha,10616936,CDM,0460,RC,94781,CPT,,,,,,outpatient,facility,,,99.00,29.70,42.08,983.0,,61.18,,,percent of total billed charges,,,,,,,,service not payable,48.31,,,percent of total billed charges,,,49.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,42.08,,,percent of total billed charges,,,,,,,,,74.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,74.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,84.15,,,percent of total billed charges,,,45.54,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,service not payable,,,,,,,865.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Additional 90 Minutes - Newborn Car Seat Study Cha,10616936,CDM,0460,RC,94781,CPT,412,EAPG,,,,outpatient,facility,,,99.00,29.70,83.86,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,83.86,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Additional 60 Minutes - Newborn Car Seat Study Cha,10616937,CDM,0460,RC,94781,CPT,,,,,,outpatient,facility,,,66.00,19.80,28.05,983.0,,40.79,,,percent of total billed charges,,,,,,,,service not payable,32.21,,,percent of total billed charges,,,33.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,33.0,,,percent of total billed charges,,,,,,,,service not payable,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,service not payable,,,,,,,865.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Additional 60 Minutes - Newborn Car Seat Study Cha,10616937,CDM,0460,RC,94781,CPT,412,EAPG,,,,outpatient,facility,,,66.00,19.80,66.0,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,66.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,66.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Additional 30 Minutes - Newborn Car Seat Study Cha,10616938,CDM,0460,RC,94781,CPT,,,,,,outpatient,facility,,,33.00,9.90,14.03,983.0,,20.39,,,percent of total billed charges,,,,,,,,service not payable,16.10,,,percent of total billed charges,,,16.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,14.03,,,percent of total billed charges,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,service not payable,24.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,15.18,,,percent of total billed charges,,,,,,,,,983.0,,,per diem,,,,,,,,service not payable,,,,,,,865.0,,,per diem,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Additional 30 Minutes - Newborn Car Seat Study Cha,10616938,CDM,0460,RC,94781,CPT,412,EAPG,,,,outpatient,facility,,,33.00,9.90,33.0,215.90,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.90,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,183.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.0,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,174.84,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,192.32,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TIBIAL BEARING PS 12MM 79/83,10617149,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL BEARING PS 12MM 79/83,10617149,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE COMP CENTRAL 45X6.5,10617150,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE COMP CENTRAL 45X6.5,10617150,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEM SZ E LT 4-6X14MM,10617151,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEM SZ E LT 4-6X14MM,10617151,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CPM 13MMX42CM 125D,10617152,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5705.00,1711.50,2213.54,4849.25,,2795.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2396.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2213.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2424.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4849.25,,,percent of total billed charges,,,2567.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CPM 13MMX42CM 125D,10617152,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5705.00,1711.50,2396.10,4849.25,,2795.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2396.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2877.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2424.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4278.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4278.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4849.25,,,percent of total billed charges,,,2624.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LAG NAT NAIL 130X10.5MM,10617153,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2333.00,699.90,905.20,1983.05,,,,,,,,,,,,,,,,,,,,905.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,991.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1749.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1166.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1983.05,,,percent of total billed charges,,,1049.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LAG NAT NAIL 130X10.5MM,10617153,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2333.00,699.90,991.52,1983.05,,,,,,,,,,,,,service not payable,,,,,,,1176.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,991.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1749.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1166.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1749.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1983.05,,,percent of total billed charges,,,1073.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN BIODUR 108 4X32MM,10617154,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BIODUR 108 4X32MM,10617154,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN BDR 108 4X38MM X_00-1147-038-41 X_ZIMME,10617155,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN BDR 108 4X38MM X_00-1147-038-41 X_ZIMME,10617155,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE RECON LKG 8H 2.7X65,10617156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1968.00,590.40,763.58,1672.8,,,,,,,,,,,,,,,,,,,,763.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1672.8,,,percent of total billed charges,,,885.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE RECON LKG 8H 2.7X65,10617156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1968.00,590.40,836.40,1672.8,,,,,,,,,,,,,service not payable,,,,,,,992.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1476.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,984.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1476.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1672.8,,,percent of total billed charges,,,905.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR XXLNG RT 24X174MM,10617157,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3793.00,1137.90,1471.68,3224.05,,,,,,,,,,,,,,,,,,,,1471.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1612.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2844.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1896.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3224.05,,,percent of total billed charges,,,1706.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR XXLNG RT 24X174MM,10617157,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3793.00,1137.90,1612.02,3224.05,,,,,,,,,,,,,service not payable,,,,,,,1913.19,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1612.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2844.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1896.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2844.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3224.05,,,percent of total billed charges,,,1744.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP SQ LK 3.5X16MM,10617158,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP SQ LK 3.5X16MM,10617158,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP SQ LK 3.5X18MM,10617159,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP SQ LK 3.5X18MM,10617159,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP SQ LK 3.5X14MM,10617160,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP SQ LK 3.5X14MM,10617160,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM LT 11.5MMX34CM 130D,10617161,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM LT 11.5MMX34CM 130D,10617161,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF LT 4-5 12MM EF,10617162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF LT 4-5 12MM EF,10617162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT TIB SZ3 12MM,10617163,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT TIB SZ3 12MM,10617163,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL AFIXS PRX HUM L 11X160MM,10617164,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL AFIXS PRX HUM L 11X160MM,10617164,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS BLNT 4X44MM,10617165,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS BLNT 4X44MM,10617165,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS BLNT 4X42MM,10617166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,787.00,236.10,305.36,668.95,,,,,,,,,,,,,,,,,,,,305.36,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,668.95,,,percent of total billed charges,,,354.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS BLNT 4X42MM,10617166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,787.00,236.10,334.47,668.95,,,,,,,,,,,,,service not payable,,,,,,,396.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,334.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,590.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,393.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,590.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,668.95,,,percent of total billed charges,,,362.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS CORT 4X32M,10617167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS CORT 4X32M,10617167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS CORT 4X30M,10617168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS CORT 4X30M,10617168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE AFFIXUS CORT 4X34M,10617169,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE AFFIXUS CORT 4X34M,10617169,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS TECNIS TORIC II 1.50 16.0,10617170,CDM,0276,RC,V2787,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS TECNIS TORIC II 1.50 16.0,10617170,CDM,0276,RC,V2787,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,1352.0,,,fee schedule,,,,,,,,service not payable,,,,,,service not payable,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,service not payable,1216.8,,,fee schedule,,,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR CROSSLOCK MINI-NAR R,10617172,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3049.00,914.70,1183.01,2591.65,,,,,,,,,,,,,,,,,,,,1183.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1295.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.65,,,percent of total billed charges,,,1372.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR CROSSLOCK MINI-NAR R,10617172,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3049.00,914.70,1295.82,2591.65,,,,,,,,,,,,,service not payable,,,,,,,1537.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1295.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2591.65,,,percent of total billed charges,,,1402.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR CROSSLOCK MINI-NAR L,10617173,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3049.00,914.70,1183.01,2591.65,,,,,,,,,,,,,,,,,,,,1183.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1295.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2286.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1524.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2591.65,,,percent of total billed charges,,,1372.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR CROSSLOCK MINI-NAR L,10617173,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3049.00,914.70,1295.82,2591.65,,,,,,,,,,,,,service not payable,,,,,,,1537.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1295.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2286.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1524.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2286.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2591.65,,,percent of total billed charges,,,1402.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTX NON-LCKG 2.4X20MM,10617174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTX NON-LCKG 2.4X20MM,10617174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING 1.3X16MM,10617175,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,345.00,103.50,133.86,293.25,,,,,,,,,,,,,,,,,,,,133.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.25,,,percent of total billed charges,,,155.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING 1.3X16MM,10617175,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,345.00,103.50,146.62,293.25,,,,,,,,,,,,,service not payable,,,,,,,174.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,258.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,158.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LOCKING 1.3X12MM,10617176,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,345.00,103.50,133.86,293.25,,,,,,,,,,,,,,,,,,,,133.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.25,,,percent of total billed charges,,,155.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LOCKING 1.3X12MM,10617176,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,345.00,103.50,146.62,293.25,,,,,,,,,,,,,service not payable,,,,,,,174.02,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,146.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,258.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,172.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,258.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,293.25,,,percent of total billed charges,,,158.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
READYWRAP CALF XL TALL BLK,10617177,CDM,0272,RC,A6545,HCPCS,,,,,,outpatient,facility,,,320.00,96.00,117.13,272.0,,197.76,,,percent of total billed charges,,,117.13,,,fee schedule,,,156.16,,,percent of total billed charges,,,161.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,246.39,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,269.01,,,fee schedule,,,,,,,,,117.13,,,fee schedule,,,,,,,,,136.0,,,percent of total billed charges,,,242.82,,,fee schedule,,,240.0,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,service not payable,119.47,,,fee schedule,,,160.0,,,percent of total billed charges,,,117.13,,,fee schedule,,,240.0,,,percent of total billed charges,,,,,,,,service not payable,119.47,,,fee schedule,,,,,,,,,272.0,,,percent of total billed charges,,,147.20,,,percent of total billed charges,,,,,,,,,208.0,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,208.0,,,percent of total billed charges,,,117.13,,,fee schedule,,,,,,,,,118.3,,,fee schedule,,,,,,,,
SHELL ACET G7 MULTI 56MM SZ F,10617178,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 MULTI 56MM SZ F,10617178,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEMORAL BIOLEX DELTA 28MM,10617179,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEMORAL BIOLEX DELTA 28MM,10617179,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART RT 8-9 CD 10MM,10617180,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,37809.00,11342.70,14669.89,32137.65,,18526.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15879.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14669.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16068.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28356.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18904.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32137.65,,,percent of total billed charges,,,17014.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART RT 8-9 CD 10MM,10617180,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,37809.00,11342.70,15879.78,32137.65,,18526.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15879.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19070.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16068.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28356.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18904.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28356.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32137.65,,,percent of total billed charges,,,17392.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT PSN ST 14X135MM,10617181,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5278.00,1583.40,2047.86,4486.30,,2586.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2216.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2047.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2243.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3958.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2639.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4486.30,,,percent of total billed charges,,,2375.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT PSN ST 14X135MM,10617181,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5278.00,1583.40,2216.76,4486.30,,2586.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2216.76,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2662.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2243.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3958.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2639.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3958.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4486.30,,,percent of total billed charges,,,2427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURFACE KN RT 10MM,10617182,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURFACE KN RT 10MM,10617182,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FIXED RT 8-11 E-F 12MM,10617183,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FIXED RT 8-11 E-F 12MM,10617183,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ 8 RT,10617184,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ 8 RT,10617184,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE MED PROX TIB 4H 3.5X94MM,10617425,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6669.00,2000.70,2587.57,5668.65,,3267.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2800.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2587.57,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2834.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5001.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3334.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5668.65,,,percent of total billed charges,,,3001.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE MED PROX TIB 4H 3.5X94MM,10617425,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6669.00,2000.70,2800.98,5668.65,,3267.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2800.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3363.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2834.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5001.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3334.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5001.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5668.65,,,percent of total billed charges,,,3067.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DISTAL RADIAL 3H LT NAR,10617432,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3538.00,1061.40,1372.74,3007.30,,,,,,,,,,,,,,,,,,,,1372.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1503.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2653.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1769.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3007.30,,,percent of total billed charges,,,1592.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DISTAL RADIAL 3H LT NAR,10617432,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3538.00,1061.40,1503.65,3007.30,,,,,,,,,,,,,service not payable,,,,,,,1784.57,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1503.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2653.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1769.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2653.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3007.30,,,percent of total billed charges,,,1627.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT NLCKING 3.5X11MM,10617434,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,634.00,190.20,245.99,538.90,,,,,,,,,,,,,,,,,,,,245.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,475.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,317.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.90,,,percent of total billed charges,,,285.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT NLCKING 3.5X11MM,10617434,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,634.00,190.20,269.45,538.90,,,,,,,,,,,,,service not payable,,,,,,,319.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,269.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,475.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,317.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,475.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,538.90,,,percent of total billed charges,,,291.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PEG THREADED LOCK 18X2.3MM,10617435,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,695.00,208.50,269.66,590.75,,,,,,,,,,,,,,,,,,,,269.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,521.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,347.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.75,,,percent of total billed charges,,,312.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEG THREADED LOCK 18X2.3MM,10617435,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,695.00,208.50,295.38,590.75,,,,,,,,,,,,,service not payable,,,,,,,350.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,295.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,521.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,347.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,521.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,590.75,,,percent of total billed charges,,,319.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR CROSSLOCK MINI RT,10617436,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3051.00,915.30,1183.79,2593.35,,,,,,,,,,,,,,,,,,,,1183.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2288.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1525.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2593.35,,,percent of total billed charges,,,1372.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR CROSSLOCK MINI RT,10617436,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3051.00,915.30,1296.68,2593.35,,,,,,,,,,,,,service not payable,,,,,,,1538.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1296.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2288.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1525.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2288.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2593.35,,,percent of total billed charges,,,1403.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM SIMPL STB 48X18MM,10617442,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6465.00,1939.50,2508.42,5495.25,,3167.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2715.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2508.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2747.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4848.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5495.25,,,percent of total billed charges,,,2909.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM SIMPL STB 48X18MM,10617442,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6465.00,1939.50,2715.30,5495.25,,3167.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2715.30,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3260.95,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2747.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4848.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4848.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5495.25,,,percent of total billed charges,,,2973.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT BEARING TIB 1.0 8.0MM,10617443,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT BEARING TIB 1.0 8.0MM,10617443,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM HP UNI SZ1 RM/LL,10617444,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4754.00,1426.20,1844.55,4040.90,,,,,,,,,,,,,,,,,,,,1844.55,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4040.90,,,percent of total billed charges,,,2139.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM HP UNI SZ1 RM/LL,10617444,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4754.00,1426.20,2020.45,4040.90,,,,,,,,,,,,,service not payable,,,,,,,2397.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2020.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3565.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2377.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3565.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4040.90,,,percent of total billed charges,,,2186.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD HUM SF SIDUS 50-18,10617445,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD HUM SF SIDUS 50-18,10617445,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX HUM LO PLT RT 7H,10617446,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4839.00,1451.70,1877.53,4113.15,,,,,,,,,,,,,,,,,,,,1877.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2056.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3629.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2419.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4113.15,,,percent of total billed charges,,,2177.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX HUM LO PLT RT 7H,10617446,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4839.00,1451.70,2056.57,4113.15,,,,,,,,,,,,,service not payable,,,,,,,2440.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2056.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3629.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2419.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3629.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4113.15,,,percent of total billed charges,,,2225.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE BONE KIRSCHNER 0.045X6MM,10617448,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,70.00,21.00,27.16,59.5,,,,,,,,,,,,,,,,,,,,27.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,52.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,31.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE BONE KIRSCHNER 0.045X6MM,10617448,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,,,,,,,,,,,,service not payable,,,,,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CAN BIOD SD NS 1/2 4X44,10617679,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CAN BIOD SD NS 1/2 4X44,10617679,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INF-IV infusion bamlanivimab/etesevimab w/monitori,10617868,CDM,0771,RC,M0245,HCPCS,,,,,,outpatient,facility,,,1016.00,304.80,101.0,863.60,,627.89,,,percent of total billed charges,,,,,,,,service not payable,495.81,,,percent of total billed charges,,,512.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,431.80,,,percent of total billed charges,,,,,,,,,762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.0,,,percent of total billed charges,,,,,,,,service not payable,762.0,,,percent of total billed charges,,,,,,,,,457.20,,,fee schedule,,,,,,,,,863.60,,,percent of total billed charges,,,467.36,,,percent of total billed charges,,,,,,,,,115.0,,,per diem,,,,,,,,service not payable,,,,,,,101.0,,,per diem,,,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
IV infusion bamlanivimab/etesevimab w/monitoring,10617872,CDM,0771,RC,M0245,HCPCS,,,,,,outpatient,facility,,,1016.00,304.80,101.0,863.60,,627.89,,,percent of total billed charges,,,,,,,,service not payable,495.81,,,percent of total billed charges,,,512.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,,431.80,,,percent of total billed charges,,,,,,,,,762.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,508.0,,,percent of total billed charges,,,,,,,,service not payable,762.0,,,percent of total billed charges,,,,,,,,,457.20,,,fee schedule,,,,,,,,,863.60,,,percent of total billed charges,,,467.36,,,percent of total billed charges,,,,,,,,,115.0,,,per diem,,,,,,,,service not payable,,,,,,,101.0,,,per diem,,,508.0,,,fee schedule,,,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE STD LT SZ 7,10617949,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE STD LT SZ 7,10617949,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SIZER BRST INSPR SCM 295ML X_MSZ-M295 X_ALLERGAN I,10617950,CDM,0274,RC,L8039,HCPCS,,,,,,inpatient,facility,,,1093.00,327.90,424.08,929.05,,,,,,,,,,,,,,,,,,,,424.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,,491.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIZER BRST INSPR SCM 295ML X_MSZ-M295 X_ALLERGAN I,10617950,CDM,0274,RC,L8039,HCPCS,,,,,,outpatient,facility,,,1093.00,327.90,464.52,929.05,,,,,,,,,,,,,service not payable,,,,,,,551.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,464.52,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,546.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,819.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,,502.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH POWERGLIDE TY 20G 10CM,10617951,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP KNEE LT TIB EF 16MM,10617953,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP KNEE LT TIB EF 16MM,10617953,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW RELINE 7.5X35MM,10617954,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3427.00,1028.10,1329.68,2912.95,,,,,,,,,,,,,,,,,,,,1329.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.95,,,percent of total billed charges,,,1542.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW RELINE 7.5X35MM,10617954,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3427.00,1028.10,1456.47,2912.95,,,,,,,,,,,,,service not payable,,,,,,,1728.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2570.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2570.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.95,,,percent of total billed charges,,,1576.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MODULUS A 10X14X34MM,10617955,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9835.00,2950.50,3815.98,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3815.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8359.75,,,percent of total billed charges,,,4425.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MODULUS A 10X14X34MM,10617955,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9835.00,2950.50,4130.70,8359.75,,4819.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4130.70,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4960.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4179.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7376.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4917.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7376.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8359.75,,,percent of total billed charges,,,4524.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD RELINE COCR 5.5MMX60MM,10617956,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1050.00,315.00,407.40,892.5,,,,,,,,,,,,,,,,,,,,407.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,525.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.5,,,percent of total billed charges,,,472.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD RELINE COCR 5.5MMX60MM,10617956,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1050.00,315.00,446.25,892.5,,,,,,,,,,,,,service not payable,,,,,,,529.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,446.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,787.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,525.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,787.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,892.5,,,percent of total billed charges,,,483.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE SPINE MOD SERV 6X17X14MM,10617957,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE SPINE MOD SERV 6X17X14MM,10617957,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK STRATUM 2.7X14MM,10617958,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,566.00,169.80,219.61,481.10,,,,,,,,,,,,,,,,,,,,219.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,424.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.10,,,percent of total billed charges,,,254.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK STRATUM 2.7X14MM,10617958,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,566.00,169.80,240.55,481.10,,,,,,,,,,,,,service not payable,,,,,,,285.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,240.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,424.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,424.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,481.10,,,percent of total billed charges,,,260.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FUSION LT STRATUM,10617960,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4144.00,1243.20,1607.87,3522.40,,,,,,,,,,,,,,,,,,,,1607.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1761.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3108.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2072.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3522.40,,,percent of total billed charges,,,1864.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FUSION LT STRATUM,10617960,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4144.00,1243.20,1761.2,3522.40,,,,,,,,,,,,,service not payable,,,,,,,2090.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1761.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3108.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2072.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3108.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3522.40,,,percent of total billed charges,,,1906.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LK STRATUM 2.7X16MM,10617962,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,566.00,169.80,219.61,481.10,,,,,,,,,,,,,,,,,,,,219.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,424.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.10,,,percent of total billed charges,,,254.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LK STRATUM 2.7X16MM,10617962,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,566.00,169.80,240.55,481.10,,,,,,,,,,,,,service not payable,,,,,,,285.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,240.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,424.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,424.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,481.10,,,percent of total billed charges,,,260.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE NL STRATUM 3.5X14MM,10617963,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,614.00,184.20,238.23,521.90,,,,,,,,,,,,,,,,,,,,238.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,460.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,307.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,521.90,,,percent of total billed charges,,,276.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE NL STRATUM 3.5X14MM,10617963,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,614.00,184.20,260.95,521.90,,,,,,,,,,,,,service not payable,,,,,,,309.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,260.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,460.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,307.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,460.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,521.90,,,percent of total billed charges,,,282.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR QTTR GL 2.9MM X_CM-9329 X_ZIMMER US INC,10617964,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1339.00,401.70,519.53,1138.15,,,,,,,,,,,,,,,,,,,,519.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,,602.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR QTTR GL 2.9MM X_CM-9329 X_ZIMMER US INC,10617964,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1339.00,401.70,569.07,1138.15,,,,,,,,,,,,,service not payable,,,,,,,675.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,,615.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR QTTR GL2  2.9MM X_CM-9329GL2 X_ZIMMER US IN,10617965,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR QTTR GL2  2.9MM X_CM-9329GL2 X_ZIMMER US IN,10617965,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.82,1231.65,,,,,,,,,,,,,service not payable,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT QUATTRO KTLS 2.9MM,10617966,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1530.00,459.00,593.64,1300.5,,,,,,,,,,,,,,,,,,,,593.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT QUATTRO KTLS 2.9MM,10617966,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,,,,,,,,,,,,service not payable,,,,,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE ST PST TRIO 4.X45MM,10617967,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3867.00,1160.10,1500.40,3286.95,,,,,,,,,,,,,,,,,,,,1500.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1643.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2900.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1933.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3286.95,,,percent of total billed charges,,,1740.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE ST PST TRIO 4.X45MM,10617967,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3867.00,1160.10,1643.47,3286.95,,,,,,,,,,,,,service not payable,,,,,,,1950.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1643.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2900.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1933.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2900.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3286.95,,,percent of total billed charges,,,1778.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ROD BONE ES2 TI HEX 5.5X35MM,10617968,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROD BONE ES2 TI HEX 5.5X35MM,10617968,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE BONE KIRSCHNER 0.028X6IN,10617970,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,70.00,21.00,27.16,59.5,,,,,,,,,,,,,,,,,,,,27.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,52.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,31.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE BONE KIRSCHNER 0.028X6IN,10617970,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,70.00,21.00,29.75,59.5,,,,,,,,,,,,,service not payable,,,,,,,35.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,29.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,52.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,35.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT GL SZ 2 2.9MM,10617971,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1339.00,401.70,519.53,1138.15,,,,,,,,,,,,,,,,,,,,519.53,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.15,,,percent of total billed charges,,,602.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT GL SZ 2 2.9MM,10617971,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1339.00,401.70,569.07,1138.15,,,,,,,,,,,,,service not payable,,,,,,,675.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,569.07,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1004.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,669.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1004.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1138.15,,,percent of total billed charges,,,615.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT GL2 PL SZ 2 2.9MM,10617972,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1449.00,434.70,562.21,1231.65,,,,,,,,,,,,,,,,,,,,562.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1231.65,,,percent of total billed charges,,,652.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT GL2 PL SZ 2 2.9MM,10617972,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1449.00,434.70,615.82,1231.65,,,,,,,,,,,,,service not payable,,,,,,,730.88,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,615.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1086.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,724.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1086.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1231.65,,,percent of total billed charges,,,666.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT KNOTLESS 2.9MM X_CM-9129 X_ZIMMER US IN,10617973,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1530.00,459.00,593.64,1300.5,,,,,,,,,,,,,,,,,,,,593.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,688.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT KNOTLESS 2.9MM X_CM-9129 X_ZIMMER US IN,10617973,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1530.00,459.00,650.25,1300.5,,,,,,,,,,,,,service not payable,,,,,,,771.73,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,650.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1147.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,765.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1300.5,,,percent of total billed charges,,,703.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CT Exam,10618083,CDM,0490,RC,50431,CPT,,,,,RT  ,outpatient,facility,,,1665.00,499.50,765.90,2912.34,,1665.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,839.83,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1415.25,,,percent of total billed charges,,,765.90,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618083,CDM,0490,RC,50431,CPT,05372,APC,,,RT  ,outpatient,facility,,,1665.00,499.50,613.95,1470.11,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1346.51,,,fee schedule,,,613.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",652.88,,,fee schedule,,,1470.11,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1327.0,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,613.95,,,fee schedule,,,652.88,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,613.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",652.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,646.45,,,fee schedule,,,,,,,,
CT Exam,10618083,CDM,0490,RC,50431,CPT,161,EAPG,,,RT  ,outpatient,facility,,,1665.00,499.50,516.46,3300.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3300.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2805.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.05,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,587.05,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,587.05,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,516.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,568.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618085,CDM,0490,RC,50431,CPT,,,,,LT  ,outpatient,facility,,,1665.00,499.50,765.90,2912.34,,1665.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,839.83,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,1248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,1248.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1415.25,,,percent of total billed charges,,,765.90,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618085,CDM,0490,RC,50431,CPT,05372,APC,,,LT  ,outpatient,facility,,,1665.00,499.50,613.95,1470.11,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1346.51,,,fee schedule,,,613.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",652.88,,,fee schedule,,,1470.11,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1327.0,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,613.95,,,fee schedule,,,652.88,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,613.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",652.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,646.45,,,fee schedule,,,,,,,,
CT Exam,10618085,CDM,0490,RC,50431,CPT,161,EAPG,,,LT  ,outpatient,facility,,,1665.00,499.50,516.46,3300.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3300.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2805.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.05,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,587.05,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,587.05,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,516.46,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,568.11,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618087,CDM,0490,RC,50431,CPT,,,,,50  ,outpatient,facility,,,3328.00,998.40,1530.88,4368.51,,3328.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4368.51,,,case rate,,,1678.64,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2457.0,,,case rate,,,,,,,,,2496.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2890.5,,,case rate,,,,,,,,,2496.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2828.80,,,percent of total billed charges,,,1530.88,,,percent of total billed charges,,,,,,,,,2662.5,,,case rate,,,,,,,,,,,,,,,2343.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618087,CDM,0490,RC,50431,CPT,05372,APC,,,50  ,outpatient,facility,,,3328.00,998.40,613.95,1470.11,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1346.51,,,fee schedule,,,613.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",652.88,,,fee schedule,,,1470.11,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,1327.0,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,613.95,,,fee schedule,,,652.88,,,fee schedule,,,,,,,,,640.08,,,fee schedule,,,,,,,,,613.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",652.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,,,,,,,640.08,,,fee schedule,,,,,,,,,646.45,,,fee schedule,,,,,,,,
CT Exam,10618087,CDM,0490,RC,50431,CPT,161,EAPG,,,50  ,outpatient,facility,,,3328.00,998.40,774.69,4950.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4950.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4208.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,880.58,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,880.58,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,880.58,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,774.69,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,852.16,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618089,CDM,0490,RC,50435,CPT,,,,,RT  ,outpatient,facility,,,2798.00,839.40,1287.08,2912.34,,2798.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1411.31,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2098.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2098.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2378.30,,,percent of total billed charges,,,1287.08,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618089,CDM,0490,RC,50435,CPT,05373,APC,,,RT  ,outpatient,facility,,,2798.00,839.40,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
CT Exam,10618089,CDM,0490,RC,50435,CPT,170,EAPG,,,RT  ,outpatient,facility,,,2798.00,839.40,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618091,CDM,0490,RC,50435,CPT,,,,,LT  ,outpatient,facility,,,2798.00,839.40,1287.08,2912.34,,2798.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,1411.31,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1638.0,,,case rate,,,,,,,,,2098.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1927.0,,,case rate,,,,,,,,,2098.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2378.30,,,percent of total billed charges,,,1287.08,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618091,CDM,0490,RC,50435,CPT,05373,APC,,,LT  ,outpatient,facility,,,2798.00,839.40,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
CT Exam,10618091,CDM,0490,RC,50435,CPT,170,EAPG,,,LT  ,outpatient,facility,,,2798.00,839.40,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618093,CDM,0490,RC,50435,CPT,,,,,50  ,outpatient,facility,,,5596.00,1678.80,2343.0,5596.0,,5596.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4368.51,,,case rate,,,2822.62,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2457.0,,,case rate,,,,,,,,,4197.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2890.5,,,case rate,,,,,,,,,4197.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4756.60,,,percent of total billed charges,,,2574.16,,,percent of total billed charges,,,,,,,,,2662.5,,,case rate,,,,,,,,,,,,,,,2343.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618093,CDM,0490,RC,50435,CPT,05373,APC,,,50  ,outpatient,facility,,,5596.00,1678.80,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
CT Exam,10618093,CDM,0490,RC,50435,CPT,170,EAPG,,,50  ,outpatient,facility,,,5596.00,1678.80,2584.47,8598.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8598.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7308.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3195.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3195.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2584.47,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2842.92,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618095,CDM,0490,RC,50432,CPT,,,,,RT  ,outpatient,facility,,,4781.00,1434.30,2199.26,5076.0,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,2411.54,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,3585.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,3585.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4063.85,,,percent of total billed charges,,,2199.26,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618095,CDM,0490,RC,50432,CPT,05373,APC,,,RT  ,outpatient,facility,,,4781.00,1434.30,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
CT Exam,10618095,CDM,0490,RC,50432,CPT,170,EAPG,,,RT  ,outpatient,facility,,,4781.00,1434.30,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618097,CDM,0490,RC,50432,CPT,,,,,LT  ,outpatient,facility,,,4781.00,1434.30,2199.26,5076.0,,4778.89,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,3666.78,,,case rate,,,2411.54,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4315.0,,,case rate,,,,,,,,,3585.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5076.0,,,case rate,,,,,,,,,3585.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4063.85,,,percent of total billed charges,,,2199.26,,,percent of total billed charges,,,,,,,,,4217.0,,,case rate,,,,,,,,,,,,,,,3711.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618097,CDM,0490,RC,50432,CPT,05373,APC,,,LT  ,outpatient,facility,,,4781.00,1434.30,1884.27,4511.86,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4132.55,,,fee schedule,,,1884.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",2003.75,,,fee schedule,,,4511.86,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,4072.66,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,1884.27,,,fee schedule,,,2003.75,,,fee schedule,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1884.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",2003.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,,,,,,,1964.46,,,fee schedule,,,,,,,,,1984.02,,,fee schedule,,,,,,,,
CT Exam,10618097,CDM,0490,RC,50432,CPT,170,EAPG,,,LT  ,outpatient,facility,,,4781.00,1434.30,1722.98,5732.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5732.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,4872.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2130.12,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1722.98,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1895.28,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CT Exam,10618099,CDM,0490,RC,50432,CPT,,,,,50  ,outpatient,facility,,,9562.00,2868.60,4398.52,8127.70,,7168.34,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5500.17,,,case rate,,,4823.07,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6472.5,,,case rate,,,,,,,,,7171.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7614.0,,,case rate,,,,,,,,,7171.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8127.70,,,percent of total billed charges,,,4398.52,,,percent of total billed charges,,,,,,,,,6325.5,,,case rate,,,,,,,,,,,,,,,5566.5,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
CT Exam,10618099,CDM,0490,RC,50432,CPT,05374,APC,,,50  ,outpatient,facility,,,9562.00,2868.60,3172.45,7596.38,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6957.75,,,fee schedule,,,3172.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3373.60,,,fee schedule,,,7596.38,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,6856.91,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,3172.45,,,fee schedule,,,3373.60,,,fee schedule,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3172.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",3373.60,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,,,,,,,3307.45,,,fee schedule,,,,,,,,,3340.39,,,fee schedule,,,,,,,,
CT Exam,10618099,CDM,0490,RC,50432,CPT,170,EAPG,,,50  ,outpatient,facility,,,9562.00,2868.60,2584.47,8598.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8598.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,7308.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3195.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,3195.18,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,2584.47,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2842.92,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
CATH BROVIAC 2.7 FR X_0600040,10618331,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,410.00,123.00,174.25,348.5,,253.38,,,percent of total billed charges,,,,,,,,service not payable,200.08,,,percent of total billed charges,,,206.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,174.25,,,percent of total billed charges,,,,,,,,,307.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,205.0,,,percent of total billed charges,,,,,,,,service not payable,307.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,,188.60,,,percent of total billed charges,,,,,,,,,266.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,266.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH BROVIAC 4.2 FR X_600520,10618333,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,645.00,193.50,274.13,548.25,,398.61,,,percent of total billed charges,,,,,,,,service not payable,314.76,,,percent of total billed charges,,,325.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,274.13,,,percent of total billed charges,,,,,,,,,483.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,322.5,,,percent of total billed charges,,,,,,,,service not payable,483.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,548.25,,,percent of total billed charges,,,296.70,,,percent of total billed charges,,,,,,,,,419.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,419.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE 130X10.2MM X_47-2485-130-10 X_ZIMMER US,10618352,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2337.00,701.10,906.76,1986.45,,,,,,,,,,,,,,,,,,,,906.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1752.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1168.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1986.45,,,percent of total billed charges,,,1051.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE 130X10.2MM X_47-2485-130-10 X_ZIMMER US,10618352,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2337.00,701.10,993.23,1986.45,,,,,,,,,,,,,service not payable,,,,,,,1178.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,993.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1752.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1168.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1752.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1986.45,,,percent of total billed charges,,,1075.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SZ 24.5 X_AU00TO 24.5 X_ALCON LAB INC,10618353,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SZ 24.5 X_AU00TO 24.5 X_ALCON LAB INC,10618353,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SZ 28.0 X_AUT00V028.0 X_ALCON LAB INC,10618354,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SZ 28.0 X_AUT00V028.0 X_ALCON LAB INC,10618354,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SZ 28.5 X_AU00T0028.5 X_ALCON LAB INC,10618355,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SZ 28.5 X_AU00T0028.5 X_ALCON LAB INC,10618355,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 29.5 X_AU00T0029.5 X_ALC,10618356,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 29.5 X_AU00T0029.5 X_ALC,10618356,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SZ 29.5 X_AU00TO 29.5 X_ALCON LAB INC,10618357,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SZ 29.5 X_AU00TO 29.5 X_ALCON LAB INC,10618357,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS SZ 22.0 X_AU00TO 22.0 X_ALCON LAB INC,10618358,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS SZ 22.0 X_AU00TO 22.0 X_ALCON LAB INC,10618358,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 6.0,10618359,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 6.0,10618359,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 9.0,10618360,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 9.0,10618360,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 9.5,10618361,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 9.5,10618361,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 10.0,10618362,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 10.0,10618362,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 10.5,10618363,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 10.5,10618363,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 11.0,10618364,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 11.0,10618364,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 11.5,10618365,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 11.5,10618365,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 12.5,10618366,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 12.5,10618366,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 14.0,10618367,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 14.0,10618367,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 14.5,10618368,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 14.5,10618368,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 15.0,10618369,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 15.0,10618369,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 15.5,10618370,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 15.5,10618370,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 16.0,10618371,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 16.0,10618371,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 16.5,10618372,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 16.5,10618372,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 17.0,10618373,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 17.0,10618373,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 17.5,10618374,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 17.5,10618374,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 18.0,10618375,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 18.0,10618375,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 18.5,10618376,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 18.5,10618376,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 19.0,10618377,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 19.0,10618377,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 20.0,10618378,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 20.0,10618378,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 20.5,10618379,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 20.5,10618379,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 21.0,10618380,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 21.0,10618380,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 21.5,10618381,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 21.5,10618381,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 22.5,10618382,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 22.5,10618382,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 23.0,10618383,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 23.0,10618383,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 23.5,10618384,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 23.5,10618384,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 24.0,10618385,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 24.0,10618385,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 25.0,10618386,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 25.0,10618386,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 25.5,10618387,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 25.5,10618387,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 26.0,10618388,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 26.0,10618388,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 26.5,10618389,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 26.5,10618389,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 27.0,10618390,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 27.0,10618390,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 27.5,10618391,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 27.5,10618391,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ARUP Amylase Body Fluid (0020506),10618642,CDM,0300,RC,82150,CPT,,,,,,outpatient,facility,,,66.00,19.80,6.16,56.10,,27.54,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,6.35,,,fee schedule,,,20.55,,,fee schedule,,,13.51,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,13.41,,,fee schedule,,,6.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.48,,,fee schedule,,,14.64,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,,,,,,,8.43,,,fee schedule,,,13.22,,,fee schedule,,,49.5,,,percent of total billed charges,,,6.35,,,fee schedule,,,6.16,,,fee schedule,,,6.48,,,fee schedule,,,9.92,,,fee schedule,,,6.35,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,6.48,,,fee schedule,,,,,,,,,56.10,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,7.13,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,6.29,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,6.41,,,fee schedule,,,,,,,,
ARUP Amylase Body Fluid (0020506),10618642,CDM,0300,RC,82150,CPT,402,EAPG,,,,outpatient,facility,,,66.00,19.80,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ARUP Glucose Body Fluid (0020503),10618643,CDM,0300,RC,82945,CPT,,,,,,outpatient,facility,,,63.00,18.90,3.73,53.55,,16.67,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,3.85,,,fee schedule,,,12.44,,,fee schedule,,,8.20,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,8.14,,,fee schedule,,,3.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",3.93,,,fee schedule,,,8.88,,,fee schedule,,,,,,,,,3.85,,,fee schedule,,,,,,,,,5.05,,,fee schedule,,,8.02,,,fee schedule,,,47.25,,,percent of total billed charges,,,3.85,,,fee schedule,,,3.73,,,fee schedule,,,3.93,,,fee schedule,,,5.94,,,fee schedule,,,3.85,,,fee schedule,,,47.25,,,percent of total billed charges,,,,,,,,,3.93,,,fee schedule,,,,,,,,,53.55,,,percent of total billed charges,,,28.98,,,percent of total billed charges,,,,,,,,,4.32,,,fee schedule,,,3.85,,,fee schedule,,,,,,,,,3.81,,,fee schedule,,,3.85,,,fee schedule,,,,,,,,,3.89,,,fee schedule,,,,,,,,
ARUP Glucose Body Fluid (0020503),10618643,CDM,0300,RC,82945,CPT,402,EAPG,,,,outpatient,facility,,,63.00,18.90,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
END-OP visit estab patient minimal care <10 min,10618644,CDM,0510,RC,99211,CPT,,,,,,outpatient,facility,,,450.00,135.00,11.49,382.5,,278.10,,,percent of total billed charges,,,,,,,,service not payable,219.60,,,percent of total billed charges,,,226.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,337.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.49,,,fee schedule,,,,,,,,service not payable,,,,,,,382.5,,,percent of total billed charges,,,207.0,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,292.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
END-OP visit estab patient minimal care <10 min,10618644,CDM,0510,RC,99211,CPT,852,EAPG,,,,outpatient,facility,,,450.00,135.00,417.08,490.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,490.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,417.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.22,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,464.44,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
ARUP LD Body Fluid (0020505),10618649,CDM,0300,RC,83615,CPT,,,,,,outpatient,facility,,,64.00,19.20,5.74,54.40,,25.64,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,5.92,,,fee schedule,,,19.13,,,fee schedule,,,12.6,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,12.5,,,fee schedule,,,5.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",6.04,,,fee schedule,,,13.65,,,fee schedule,,,,,,,,,5.92,,,fee schedule,,,,,,,,,7.58,,,fee schedule,,,12.32,,,fee schedule,,,48.0,,,percent of total billed charges,,,5.92,,,fee schedule,,,5.74,,,fee schedule,,,6.04,,,fee schedule,,,8.91,,,fee schedule,,,5.92,,,fee schedule,,,48.0,,,percent of total billed charges,,,,,,,,,6.04,,,fee schedule,,,,,,,,,54.40,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,6.64,,,fee schedule,,,5.92,,,fee schedule,,,,,,,,,5.86,,,fee schedule,,,5.92,,,fee schedule,,,,,,,,,5.98,,,fee schedule,,,,,,,,
ARUP LD Body Fluid (0020505),10618649,CDM,0300,RC,83615,CPT,402,EAPG,,,,outpatient,facility,,,64.00,19.20,6.43,29.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,23.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,26.66,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,29.33,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GUIDEWIRE BONE NITINOL 1.6MM,10618783,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,608.00,182.40,258.40,516.80,,375.74,,,percent of total billed charges,,,,,,,,service not payable,296.70,,,percent of total billed charges,,,306.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,258.40,,,percent of total billed charges,,,,,,,,,456.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,304.0,,,percent of total billed charges,,,,,,,,service not payable,456.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,516.80,,,percent of total billed charges,,,279.68,,,percent of total billed charges,,,,,,,,,395.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,395.20,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 16MM THD 7.0X105MM,10618784,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1131.00,339.30,438.83,961.35,,,,,,,,,,,,,,,,,,,,438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.35,,,percent of total billed charges,,,508.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 16MM THD 7.0X105MM,10618784,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1131.00,339.30,480.68,961.35,,,,,,,,,,,,,service not payable,,,,,,,570.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,848.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,961.35,,,percent of total billed charges,,,520.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 32MM THD 7.0X105MM,10618785,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1131.00,339.30,438.83,961.35,,,,,,,,,,,,,,,,,,,,438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.35,,,percent of total billed charges,,,508.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 32MM THD 7.0X105MM,10618785,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1131.00,339.30,480.68,961.35,,,,,,,,,,,,,service not payable,,,,,,,570.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,848.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,961.35,,,percent of total billed charges,,,520.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC DISTAL SZ 11,10618787,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC DISTAL SZ 11,10618787,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN THD 32MM 7X85MM,10618788,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1131.00,339.30,438.83,961.35,,,,,,,,,,,,,,,,,,,,438.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.35,,,percent of total billed charges,,,508.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN THD 32MM 7X85MM,10618788,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1131.00,339.30,480.68,961.35,,,,,,,,,,,,,service not payable,,,,,,,570.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,480.68,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,848.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,565.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,848.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,961.35,,,percent of total billed charges,,,520.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KN LT 6-9 EF 11MM,10618789,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KN LT 6-9 EF 11MM,10618789,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE DVR LONG LT 24X85MM,10618790,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3679.00,1103.70,1427.45,3127.15,,,,,,,,,,,,,,,,,,,,1427.45,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1563.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2759.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1839.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3127.15,,,percent of total billed charges,,,1655.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE DVR LONG LT 24X85MM,10618790,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3679.00,1103.70,1563.58,3127.15,,,,,,,,,,,,,service not payable,,,,,,,1855.69,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1563.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2759.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1839.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2759.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3127.15,,,percent of total billed charges,,,1692.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VENOUS 80CM 16X100MM,10618791,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4672.00,1401.60,1812.74,3971.20,,,,,,,,,,,,,,,,,,,,1812.74,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1985.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3504.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2336.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3971.20,,,percent of total billed charges,,,2102.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VENOUS 80CM 16X100MM,10618791,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4672.00,1401.60,1985.60,3971.20,,,,,,,,,,,,,service not payable,,,,,,,2356.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1985.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3504.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2336.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3504.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3971.20,,,percent of total billed charges,,,2149.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BALLOON PTA ATLAS GLD 16X6X120,10618792,CDM,0278,RC,C1725,HCPCS,,,,,,inpatient,facility,,,1426.00,427.80,553.29,1212.10,,,,,,,,,,,,,,,,,,,,553.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,606.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1069.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1212.10,,,percent of total billed charges,,,641.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALLOON PTA ATLAS GLD 16X6X120,10618792,CDM,0278,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1426.00,427.80,606.05,1212.10,,,,,,,,,,,,,service not payable,,,,,,,719.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,606.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1069.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1069.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1212.10,,,percent of total billed charges,,,655.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SM HEX RECESS 2.7X28MM,10618793,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,191.00,57.30,74.11,162.35,,,,,,,,,,,,,,,,,,,,74.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.35,,,percent of total billed charges,,,85.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SM HEX RECESS 2.7X28MM,10618793,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,191.00,57.30,81.17,162.35,,,,,,,,,,,,,service not payable,,,,,,,96.34,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,81.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,143.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,95.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,143.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,162.35,,,percent of total billed charges,,,87.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE BONE 1/4 TUBULAR 6H 47MM,10618794,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE BONE 1/4 TUBULAR 6H 47MM,10618794,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM LNG 11.5MMX40CM 130D,10618795,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM LNG 11.5MMX40CM 130D,10618795,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 LONGEVITY 36MM SZG,10618796,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 LONGEVITY 36MM SZG,10618796,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMORAL TPRLC PPS SZ16,10618797,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMORAL TPRLC PPS SZ16,10618797,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VAS PROPATEN 4-6MMX45CM,10618798,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,4027.00,1208.10,1562.48,3422.95,,,,,,,,,,,,,,,,,,,,1562.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3422.95,,,percent of total billed charges,,,1812.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VAS PROPATEN 4-6MMX45CM,10618798,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,4027.00,1208.10,1711.47,3422.95,,,,,,,,,,,,,service not payable,,,,,,,2031.22,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1711.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3020.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2013.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3020.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3422.95,,,percent of total billed charges,,,1852.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Treponema pallidum Antibody by TP-PA (0050777),10619223,CDM,0300,RC,86780,CPT,,,,,,outpatient,facility,,,70.00,21.00,12.58,59.5,,24.89,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,12.98,,,fee schedule,,,18.57,,,fee schedule,,,27.62,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,27.41,,,fee schedule,,,12.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.24,,,fee schedule,,,29.92,,,fee schedule,,,,,,,,,12.98,,,fee schedule,,,,,,,,,16.85,,,fee schedule,,,27.01,,,fee schedule,,,52.5,,,percent of total billed charges,,,12.98,,,fee schedule,,,12.58,,,fee schedule,,,13.24,,,fee schedule,,,19.82,,,fee schedule,,,12.98,,,fee schedule,,,52.5,,,percent of total billed charges,,,12.58,,,fee schedule,,,13.24,,,fee schedule,,,,,,,,,59.5,,,percent of total billed charges,,,32.20,,,percent of total billed charges,,,,,,,,,14.56,,,fee schedule,,,12.98,,,fee schedule,,,,,,,,,12.84,,,fee schedule,,,12.98,,,fee schedule,,,,,,,,,13.1,,,fee schedule,,,,,,,,
Treponema pallidum Antibody by TP-PA (0050777),10619223,CDM,0300,RC,86780,CPT,394,EAPG,,,,outpatient,facility,,,70.00,21.00,13.66,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,13.66,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,33.48,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,36.83,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
KIT MIDLINE PWR GLIDE 20G 10CM,10619525,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,633.00,189.90,269.02,538.05,,391.19,,,percent of total billed charges,,,,,,,,service not payable,308.90,,,percent of total billed charges,,,319.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,269.02,,,percent of total billed charges,,,,,,,,,474.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,474.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,538.05,,,percent of total billed charges,,,291.18,,,percent of total billed charges,,,,,,,,,411.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,411.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT MIDLINE PWR GLIDE 20G 8CM,10619526,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,738.00,221.40,313.65,627.30,,456.08,,,percent of total billed charges,,,,,,,,service not payable,360.14,,,percent of total billed charges,,,372.25,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,,,,,,,553.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,369.0,,,percent of total billed charges,,,,,,,,service not payable,553.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,627.30,,,percent of total billed charges,,,339.48,,,percent of total billed charges,,,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,479.70,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT MIDLINE GUARDIVA 20G 8CM,10619527,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,633.00,189.90,269.02,538.05,,391.19,,,percent of total billed charges,,,,,,,,service not payable,308.90,,,percent of total billed charges,,,319.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,269.02,,,percent of total billed charges,,,,,,,,,474.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,316.5,,,percent of total billed charges,,,,,,,,service not payable,474.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,538.05,,,percent of total billed charges,,,291.18,,,percent of total billed charges,,,,,,,,,411.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,411.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE RT 4-11 10MM,10619528,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE RT 4-11 10MM,10619528,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SUTURE TIGERTAPE 2MM 48IN,10619532,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE TIGERTAPE 2MM 48IN,10619532,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE PEG 2.5X18MM,10619533,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,713.00,213.90,276.64,606.05,,,,,,,,,,,,,,,,,,,,276.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,534.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,356.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,606.05,,,percent of total billed charges,,,320.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE PEG 2.5X18MM,10619533,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,713.00,213.90,303.02,606.05,,,,,,,,,,,,,service not payable,,,,,,,359.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,303.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,534.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,356.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,534.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,606.05,,,percent of total billed charges,,,327.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE POLYAXIAL 6.5X55MM,10619534,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE POLYAXIAL 6.5X55MM,10619534,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE POLYAXIAL 5.5X50MM,10619535,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE POLYAXIAL 5.5X50MM,10619535,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE POLYAXIAL 6.5X50MM,10619536,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE POLYAXIAL 6.5X50MM,10619536,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHAFT DRIVE WRIST HEXALOBE,10619537,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,820.00,246.00,318.16,697.0,,,,,,,,,,,,,,,,,,,,318.16,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.0,,,percent of total billed charges,,,369.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHAFT DRIVE WRIST HEXALOBE,10619537,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,820.00,246.00,348.5,697.0,,,,,,,,,,,,,service not payable,,,,,,,413.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,348.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,615.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,410.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,615.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,697.0,,,percent of total billed charges,,,377.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MODULAR HEAD COMPONENT 40MM,10619538,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MODULAR HEAD COMPONENT 40MM,10619538,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NEXGEN ART SURFACE SZ E F 10MM,10619539,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEXGEN ART SURFACE SZ E F 10MM,10619539,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NXT RT SZ E,10619540,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5410.00,1623.00,2099.08,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2099.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.5,,,percent of total billed charges,,,2434.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NXT RT SZ E,10619540,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5410.00,1623.00,2272.20,4598.5,,2650.90,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2272.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2728.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2299.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4057.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2705.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4057.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4598.5,,,percent of total billed charges,,,2488.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NXT LT SZ F,10619541,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NXT LT SZ F,10619541,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CRTCL Z NAIL 13X38MM,10619542,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CRTCL Z NAIL 13X38MM,10619542,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FUSION RT STRATUM,10619543,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4144.00,1243.20,1607.87,3522.40,,,,,,,,,,,,,,,,,,,,1607.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1761.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3108.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2072.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3522.40,,,percent of total billed charges,,,1864.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FUSION RT STRATUM,10619543,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4144.00,1243.20,1761.2,3522.40,,,,,,,,,,,,,service not payable,,,,,,,2090.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1761.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3108.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2072.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3108.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3522.40,,,percent of total billed charges,,,1906.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE NL STRATUM 3.5X20MM,10619544,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,861.00,258.30,334.07,731.85,,,,,,,,,,,,,,,,,,,,334.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.85,,,percent of total billed charges,,,387.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE NL STRATUM 3.5X20MM,10619544,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,861.00,258.30,365.93,731.85,,,,,,,,,,,,,service not payable,,,,,,,434.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,645.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,396.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE STRATUM NL 3.5X20MM,10619545,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,369.00,110.70,143.17,313.65,,,,,,,,,,,,,,,,,,,,143.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,276.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.65,,,percent of total billed charges,,,166.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE STRATUM NL 3.5X20MM,10619545,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,369.00,110.70,156.82,313.65,,,,,,,,,,,,,service not payable,,,,,,,186.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,156.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,276.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,184.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,276.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,313.65,,,percent of total billed charges,,,169.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE STRATM LK 2.7X20 ST,10619546,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,566.00,169.80,219.61,481.10,,,,,,,,,,,,,,,,,,,,219.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,424.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.10,,,percent of total billed charges,,,254.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE STRATM LK 2.7X20 ST,10619546,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,566.00,169.80,240.55,481.10,,,,,,,,,,,,,service not payable,,,,,,,285.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,240.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,424.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,283.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,424.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,481.10,,,percent of total billed charges,,,260.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Cardiopulmonary resuscitation,10619686,CDM,0480,RC,92950,CPT,,,,,,outpatient,facility,,,1264.00,379.20,537.20,2075.0,,781.15,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,637.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.20,,,percent of total billed charges,,,,,,,,,948.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,632.0,,,percent of total billed charges,,,,,,,,,948.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1074.40,,,percent of total billed charges,,,581.44,,,percent of total billed charges,,,,,,,,,2075.0,,,per diem,,,,,,,,,,,,,,,1826.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
Cardiopulmonary resuscitation,10619686,CDM,0480,RC,92950,CPT,05722,APC,,,,outpatient,facility,,,1264.00,379.20,286.43,685.86,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,628.20,,,fee schedule,,,286.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",304.59,,,fee schedule,,,685.86,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,619.10,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,286.43,,,fee schedule,,,304.59,,,fee schedule,,,,,,,,,298.62,,,fee schedule,,,,,,,,,286.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",304.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,,,,,,,298.62,,,fee schedule,,,,,,,,,301.59,,,fee schedule,,,,,,,,
Cardiopulmonary resuscitation,10619686,CDM,0480,RC,92950,CPT,92,EAPG,,,,outpatient,facility,,,1264.00,379.20,1022.57,3274.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3274.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,2783.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1022.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1022.57,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1839.54,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,2023.49,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
TUBE VENTILATION PC 1.35MM,10620045,CDM,0278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,147.00,44.10,57.04,124.95,,,,,,,,,,,,,,,,,,,,57.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,110.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.95,,,percent of total billed charges,,,66.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBE VENTILATION PC 1.35MM,10620045,CDM,0278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,147.00,44.10,62.48,124.95,,,,,,,,,,,,,service not payable,,,,,,,74.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,62.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,110.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,110.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,124.95,,,percent of total billed charges,,,67.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 19.0,10620820,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 19.0,10620820,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 19.5,10620821,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 19.5,10620821,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 20.0,10620822,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 20.0,10620822,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 20.5,10620823,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 20.5,10620823,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 22.0,10620824,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 22.0,10620824,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 22.5,10620825,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 22.5,10620825,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM LAT ECHO 11X135MM,10620827,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM LAT ECHO 11X135MM,10620827,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE MAX MICRO 2.3X7MM,10620828,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,289.00,86.70,112.13,245.65,,,,,,,,,,,,,,,,,,,,112.13,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.82,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,216.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.65,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE MAX MICRO 2.3X7MM,10620828,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,289.00,86.70,122.82,245.65,,,,,,,,,,,,,service not payable,,,,,,,145.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,122.82,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,216.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,144.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,216.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,245.65,,,percent of total billed charges,,,132.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE COMP 12H 4.5X199MM,10620829,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1393.00,417.90,540.48,1184.05,,,,,,,,,,,,,,,,,,,,540.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1184.05,,,percent of total billed charges,,,626.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE COMP 12H 4.5X199MM,10620829,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1393.00,417.90,592.02,1184.05,,,,,,,,,,,,,service not payable,,,,,,,702.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,592.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1044.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,696.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1044.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1184.05,,,percent of total billed charges,,,640.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT HEAD ENDO II SZ46,10620830,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT HEAD ENDO II SZ46,10620830,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT MAIN BODY AFX2 28X120MM,10620831,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,32780.00,9834.00,12718.64,27863.0,,16062.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13767.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,12718.64,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13931.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24585.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16390.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27863.0,,,percent of total billed charges,,,14751.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT MAIN BODY AFX2 28X120MM,10620831,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,32780.00,9834.00,13767.6,27863.0,,16062.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13767.6,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,16534.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,13931.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,24585.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,16390.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,24585.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,27863.0,,,percent of total billed charges,,,15078.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PACEMAKER BIV SERENA MRI CRT P,10620832,CDM,0278,RC,C2621,HCPCS,,,,,,inpatient,facility,,,20683.00,6204.90,8025.00,17580.55,,10134.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8686.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8025.00,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8790.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15512.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10341.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17580.55,,,percent of total billed charges,,,9307.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACEMAKER BIV SERENA MRI CRT P,10620832,CDM,0278,RC,C2621,HCPCS,,,,,,outpatient,facility,,,20683.00,6204.90,8686.86,17580.55,,10134.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8686.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10432.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8790.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10341.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15512.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17580.55,,,percent of total billed charges,,,9514.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STENT VIABAHN 8F 10MMX5CM,10620833,CDM,0278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,9372.00,2811.60,3636.34,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3636.34,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7966.20,,,percent of total billed charges,,,4217.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STENT VIABAHN 8F 10MMX5CM,10620833,CDM,0278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,9372.00,2811.60,3936.24,7966.20,,4592.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3936.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4727.24,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3983.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7029.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4686.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7029.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7966.20,,,percent of total billed charges,,,4311.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM DISTAL CENTRALIZER 17MM,10620835,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,520.00,156.00,201.76,442.0,,,,,,,,,,,,,,,,,,,,201.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.0,,,percent of total billed charges,,,234.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM DISTAL CENTRALIZER 17MM,10620835,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,,,,,,,,,,,,service not payable,,,,,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM ECHO FX COCR 11MM,10620836,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,520.00,156.00,201.76,442.0,,,,,,,,,,,,,,,,,,,,201.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.0,,,percent of total billed charges,,,234.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM ECHO FX COCR 11MM,10620836,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,,,,,,,,,,,,service not payable,,,,,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 12.0,10620837,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 12.0,10620837,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 13.0,10620838,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 13.0,10620838,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IOL ULTRASERT SYS SZ 13.5,10620839,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IOL ULTRASERT SYS SZ 13.5,10620839,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Revasc w/Arthrectomy FemPop Artery,10621152,CDM,0481,RC,37225,CPT,,,,,,outpatient,facility,,,30597.00,9179.10,5463.36,26007.45,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,15433.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15796.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26007.45,,,percent of total billed charges,,,14074.62,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,,,,,,,,13747.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Revasc w/Arthrectomy FemPop Artery,10621152,CDM,0481,RC,37225,CPT,05194,APC,,,,outpatient,facility,,,30597.00,9179.10,16517.06,39549.77,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,36224.79,,,fee schedule,,,16517.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17527.09,,,fee schedule,,,39549.77,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,35699.80,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,16517.06,,,fee schedule,,,17527.09,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,16517.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",17527.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,17354.92,,,fee schedule,,,,,,,,
Revasc w/Arthrectomy FemPop Artery,10621152,CDM,0481,RC,37225,CPT,85,EAPG,,,,outpatient,facility,,,30597.00,9179.10,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
PLATE TIB STEM PRECOAT SZ3,10621182,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2950.00,885.00,1144.60,2507.5,,,,,,,,,,,,,,,,,,,,1144.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2507.5,,,percent of total billed charges,,,1327.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE TIB STEM PRECOAT SZ3,10621182,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2950.00,885.00,1253.75,2507.5,,,,,,,,,,,,,service not payable,,,,,,,1487.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1253.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2212.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1475.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2212.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2507.5,,,percent of total billed charges,,,1357.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM LONG 32MM 6DEG,10621183,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM LONG 32MM 6DEG,10621183,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER LONGEVITY SZ J 32MM,10621184,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4951.00,1485.30,1920.99,4208.35,,,,,,,,,,,,,,,,,,,,1920.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2104.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3713.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2475.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4208.35,,,percent of total billed charges,,,2227.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER LONGEVITY SZ J 32MM,10621184,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4951.00,1485.30,2104.17,4208.35,,,,,,,,,,,,,service not payable,,,,,,,2497.28,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2104.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3713.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2475.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3713.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4208.35,,,percent of total billed charges,,,2277.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE RT SZ 12,10621185,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE RT SZ 12,10621185,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 LONGEVITY 32MM SZ D,10621186,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 LONGEVITY 32MM SZ D,10621186,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRCL 12X144MM,10621187,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRCL 12X144MM,10621187,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD MODULAR 32MM -6,10621188,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD MODULAR 32MM -6,10621188,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ASSEMBLY ULNAR C/M ELBOW LT,10621189,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,6229.00,1868.70,2416.85,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2416.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5294.65,,,percent of total billed charges,,,2803.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASSEMBLY ULNAR C/M ELBOW LT,10621189,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,6229.00,1868.70,2616.18,5294.65,,3052.21,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2616.18,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3141.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2647.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4671.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3114.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4671.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5294.65,,,percent of total billed charges,,,2865.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ASSEMBLY HUMERAL 6IN,10621190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17703.00,5310.90,6868.76,15047.55,,8674.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7435.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6868.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13277.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8851.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15047.55,,,percent of total billed charges,,,7966.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASSEMBLY HUMERAL 6IN,10621190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17703.00,5310.90,7435.26,15047.55,,8674.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7435.26,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8929.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7523.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13277.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8851.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13277.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15047.55,,,percent of total billed charges,,,8143.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN RT SZ 7,10621191,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN RT SZ 7,10621191,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ART 11MM RT EF,10621192,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ART 11MM RT EF,10621192,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE BRNG LT 14MM,10621193,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE BRNG LT 14MM,10621193,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIBIAL TRIATHLON CR X3,10621194,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIBIAL TRIATHLON CR X3,10621194,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING TIBIAL 12MM 79/83 PS,10621196,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING TIBIAL 12MM 79/83 PS,10621196,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
I and D Peritonsillar Abscess,10622817,CDM,0490,RC,42700,CPT,,,,,,outpatient,facility,,,649.00,194.70,298.54,2912.34,,649.0,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,2912.34,,,case rate,,,327.36,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,52.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.0,,,case rate,,,,,,,,,486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.0,,,case rate,,,,,,,,,486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,551.65,,,percent of total billed charges,,,298.54,,,percent of total billed charges,,,,,,,,,1775.0,,,case rate,,,,,,,,,,,,,,,1562.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
I and D Peritonsillar Abscess,10622817,CDM,0490,RC,42700,CPT,05161,APC,,,,outpatient,facility,,,649.00,194.70,213.60,511.46,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,468.46,,,fee schedule,,,213.60,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",227.14,,,fee schedule,,,511.46,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,461.67,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,213.60,,,fee schedule,,,227.14,,,fee schedule,,,,,,,,,222.69,,,fee schedule,,,,,,,,,213.60,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",227.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.69,,,fee schedule,,,,,,,,,,,,,,,222.69,,,fee schedule,,,,,,,,,224.90,,,fee schedule,,,,,,,,
I and D Peritonsillar Abscess,10622817,CDM,0490,RC,42700,CPT,249,EAPG,,,,outpatient,facility,,,649.00,194.70,246.43,776.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,776.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,660.30,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,246.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,246.43,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,272.18,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,299.40,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LENS IQ PANOPTIX TRIFOCAL 8.5,10622841,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 8.5,10622841,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 8.0,10622842,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 8.0,10622842,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 9.0,10622843,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 9.0,10622843,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ PANOPTIX TRIFOCAL 9.5,10622844,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ PANOPTIX TRIFOCAL 9.5,10622844,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPONENT FEMUR PSN S8 R,10622845,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11227.00,3368.10,4356.08,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4356.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9542.95,,,percent of total billed charges,,,5052.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPONENT FEMUR PSN S8 R,10622845,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11227.00,3368.10,4715.34,9542.95,,5501.23,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4715.34,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5662.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4771.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8420.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5613.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8420.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9542.95,,,percent of total billed charges,,,5164.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC KNEE VE R 12MM 6-9,10622846,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC KNEE VE R 12MM 6-9,10622846,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 5.25D 19.0,10622847,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 5.25D 19.0,10622847,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT HALF RM CD 10MM,10622848,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT HALF RM CD 10MM,10622848,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE TIB REV PSN FIX TIB,10622849,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,16801.00,5040.30,6518.79,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6518.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14280.85,,,percent of total billed charges,,,7560.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE TIB REV PSN FIX TIB,10622849,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,16801.00,5040.30,7056.42,14280.85,,8232.49,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7056.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8474.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7140.43,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12600.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,8400.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12600.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,14280.85,,,percent of total billed charges,,,7728.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 3.5X56MM,10622850,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 3.5X56MM,10622850,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP 3.5X58MM,10622851,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,328.00,98.40,127.26,278.80,,,,,,,,,,,,,,,,,,,,127.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.80,,,percent of total billed charges,,,147.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP 3.5X58MM,10622851,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,328.00,98.40,139.40,278.80,,,,,,,,,,,,,service not payable,,,,,,,165.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,139.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,246.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,164.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,246.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,278.80,,,percent of total billed charges,,,150.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 3.5X52MM,10622852,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 3.5X52MM,10622852,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LP LCKG 3.5X54MM,10622853,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LP LCKG 3.5X54MM,10622853,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTICULAR PSN RT 14MM,10622854,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTICULAR PSN RT 14MM,10622854,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Atherectomy w/stent tibial artery,10622951,CDM,0481,RC,37231,CPT,,,,,,outpatient,facility,,,48649.00,14594.70,5463.36,41351.65,,7120.36,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,5463.36,,,case rate,,,24538.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32559.0,,,case rate,,,,,,,,,36486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38305.0,,,case rate,,,,,,,,,36486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41351.65,,,percent of total billed charges,,,22378.54,,,percent of total billed charges,,,,,,,,,40166.0,,,case rate,,,,,,,,,,,,,,,35346.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Atherectomy w/stent tibial artery,10622951,CDM,0481,RC,37231,CPT,05194,APC,,,,outpatient,facility,,,48649.00,14594.70,16517.06,39549.77,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,36224.79,,,fee schedule,,,16517.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",17527.09,,,fee schedule,,,39549.77,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,35699.80,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,16517.06,,,fee schedule,,,17527.09,,,fee schedule,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,16517.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",17527.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,,,,,,,17183.42,,,fee schedule,,,,,,,,,17354.92,,,fee schedule,,,,,,,,
Atherectomy w/stent tibial artery,10622951,CDM,0481,RC,37231,CPT,85,EAPG,,,,outpatient,facility,,,48649.00,14594.70,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
Atherectomy/PTA tib artery ea addtl vessel,10622954,CDM,0481,RC,37233,CPT,,,,,,outpatient,facility,,,30597.00,9179.10,2912.34,26007.45,,3795.64,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,service not payable,2912.34,,,case rate,,,15433.13,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,15796.0,,,case rate,,,,,,,,,22947.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,18583.0,,,case rate,,,,,,,,service not payable,22947.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,26007.45,,,percent of total billed charges,,,14074.62,,,percent of total billed charges,,,,,,,,,15622.0,,,case rate,,,,,,,,service not payable,,,,,,,13747.0,,,case rate,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Atherectomy/PTA tib artery ea addtl vessel,10622954,CDM,0481,RC,37233,CPT,85,EAPG,,,,outpatient,facility,,,30597.00,9179.10,8921.80,22316.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22316.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,18969.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15562.24,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,8921.80,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,9813.98,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GLIDESCOPE BFLEX BRONCHO 5.8MM X_0570-0397 X_36965,10623113,CDM,0278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1700.00,510.00,659.60,1445.0,,,,,,,,,,,,,,,,,,,,659.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1275.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,850.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1445.0,,,percent of total billed charges,,,765.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIDESCOPE BFLEX BRONCHO 5.8MM X_0570-0397 X_36965,10623113,CDM,0278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1700.00,510.00,722.5,1445.0,,,,,,,,,,,,,service not payable,,,,,,,857.48,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,722.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1275.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,850.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1275.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1445.0,,,percent of total billed charges,,,782.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK MARKER FIDUCIAL MRI BREA,10623148,CDM,0278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK MARKER FIDUCIAL MRI BREA,10623148,CDM,0278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE NASAL PDS 0.25X50X40MM,10623150,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE NASAL PDS 0.25X50X40MM,10623150,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ENDO II UNIPOLAR 51MM,10623151,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ENDO II UNIPOLAR 51MM,10623151,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
IMPL KNEE RT 16MM SZ 7-9 EF,10623152,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMPL KNEE RT 16MM SZ 7-9 EF,10623152,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT OFFSET 6MM 13X135MM,10623153,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8524.00,2557.20,3307.31,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3307.31,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7245.40,,,percent of total billed charges,,,3835.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT OFFSET 6MM 13X135MM,10623153,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8524.00,2557.20,3580.08,7245.40,,4176.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3580.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4299.51,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3622.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6393.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4262.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6393.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7245.40,,,percent of total billed charges,,,3921.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT PATELLA KNEE MD 19.5MM,10623154,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,10245.00,3073.50,3975.06,8708.25,,5020.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4302.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3975.06,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4354.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7683.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5122.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8708.25,,,percent of total billed charges,,,4610.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT PATELLA KNEE MD 19.5MM,10623154,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,10245.00,3073.50,4302.90,8708.25,,5020.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4302.90,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5167.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4354.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,7683.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5122.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7683.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,8708.25,,,percent of total billed charges,,,4712.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM NAT 125D 11.5MMX36CM,10623156,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5709.00,1712.70,2215.09,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4852.65,,,percent of total billed charges,,,2569.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM NAT 125D 11.5MMX36CM,10623156,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5709.00,1712.70,2397.78,4852.65,,2797.41,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2397.78,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2879.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2426.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4281.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2854.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4281.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4852.65,,,percent of total billed charges,,,2626.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIA PSN REV FX SZC RT,10623157,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8376.00,2512.80,3249.89,7119.60,,4104.24,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3517.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3249.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3559.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6282.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4188.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7119.60,,,percent of total billed charges,,,3769.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIA PSN REV FX SZC RT,10623157,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8376.00,2512.80,3517.92,7119.60,,4104.24,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3517.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4224.85,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3559.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6282.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4188.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6282.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7119.60,,,percent of total billed charges,,,3852.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT RT LAT SZCD 5MM,10623158,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT RT LAT SZCD 5MM,10623158,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUGMENT RT MED SZCD 5MM,10623159,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUGMENT RT MED SZCD 5MM,10623159,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 18MM RT,10623160,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 18MM RT,10623160,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 7X23X11 6DEG,10623161,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10924.00,3277.20,4238.51,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4238.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9285.40,,,percent of total billed charges,,,4915.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 7X23X11 6DEG,10623161,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10924.00,3277.20,4588.08,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5510.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9285.40,,,percent of total billed charges,,,5025.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE POST LUM 7X28X11 6DEG,10623162,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,10924.00,3277.20,4238.51,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4238.51,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9285.40,,,percent of total billed charges,,,4915.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE POST LUM 7X28X11 6DEG,10623162,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,10924.00,3277.20,4588.08,9285.40,,5352.76,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4588.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5510.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4642.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5462.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8193.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9285.40,,,percent of total billed charges,,,5025.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
JOINT FINGER IMPLANT SZ20,10623164,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5705.00,1711.50,2213.54,4849.25,,2795.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2396.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2213.54,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2424.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2852.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4849.25,,,percent of total billed charges,,,2567.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
JOINT FINGER IMPLANT SZ20,10623164,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5705.00,1711.50,2396.10,4849.25,,2795.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2396.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2877.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2424.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4278.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2852.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4278.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4849.25,,,percent of total billed charges,,,2624.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTAP LH 4.5X30MM,10623166,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTAP LH 4.5X30MM,10623166,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTAP LH 4.5X32MM,10623167,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTAP LH 4.5X32MM,10623167,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT SLFTAP LH 4.5X34MM,10623168,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,247.00,74.10,95.84,209.95,,,,,,,,,,,,,,,,,,,,95.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,111.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT SLFTAP LH 4.5X34MM,10623168,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,247.00,74.10,104.97,209.95,,,,,,,,,,,,,service not payable,,,,,,,124.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,104.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,185.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,123.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,185.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,209.95,,,percent of total billed charges,,,113.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 1/3 THD 4.0X40MM,10623170,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 1/3 THD 4.0X40MM,10623170,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT OSTEOCHONDRAL FEM 16MM,10623513,CDM,0278,RC,C9359,HCPCS,,,,,,inpatient,facility,,,14752.00,4425.60,5723.78,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5723.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12539.20,,,percent of total billed charges,,,6638.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT OSTEOCHONDRAL FEM 16MM,10623513,CDM,0278,RC,C9359,HCPCS,,,,,,outpatient,facility,,,14752.00,4425.60,6195.84,12539.20,,7228.48,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6195.84,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7440.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6269.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11064.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7376.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11064.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12539.20,,,percent of total billed charges,,,6785.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT OSTEOCHONDRAL FEM 16MM,10623513,CDM,0278,RC,C9359,HCPCS,455,EAPG,,,,outpatient,facility,,,14752.00,4425.60,3016.98,3549.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3549.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,3016.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE NASAL PDS 0.15X50X40MM,10623563,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE NASAL PDS 0.15X50X40MM,10623563,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW SPINE PROBE PEDICLE 3MM,10623564,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,563.00,168.90,218.44,478.55,,,,,,,,,,,,,,,,,,,,218.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.55,,,percent of total billed charges,,,253.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW SPINE PROBE PEDICLE 3MM,10623564,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,563.00,168.90,239.28,478.55,,,,,,,,,,,,,service not payable,,,,,,,283.98,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,239.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,422.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,281.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,422.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,478.55,,,percent of total billed charges,,,258.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
MESH 15/17MM DYNAMICSTD LARGE,10623565,CDM,0278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,14884.00,4465.20,5774.99,12651.4,,7293.16,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6251.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,5774.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6325.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11163.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7442.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12651.4,,,percent of total billed charges,,,6697.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESH 15/17MM DYNAMICSTD LARGE,10623565,CDM,0278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,14884.00,4465.20,6251.28,12651.4,,7293.16,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6251.28,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,7507.49,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6325.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11163.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7442.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11163.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,12651.4,,,percent of total billed charges,,,6846.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE VASC 40CM 0.018IN X_7306V X_TELEFLEX INC,10623566,CDM,0278,RC,C1769,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUIDEWIRE VASC 40CM 0.018IN X_7306V X_TELEFLEX INC,10623566,CDM,0278,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Prolactin Dilution Study (0020724),10623669,CDM,0300,RC,84146,CPT,,,,,,outpatient,facility,,,68.00,20.40,18.41,68.0,,68.0,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,18.99,,,fee schedule,,,61.44,,,fee schedule,,,40.42,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,40.12,,,fee schedule,,,18.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",19.37,,,fee schedule,,,43.80,,,fee schedule,,,,,,,,,18.99,,,fee schedule,,,,,,,,,24.86,,,fee schedule,,,39.54,,,fee schedule,,,51.0,,,percent of total billed charges,,,18.99,,,fee schedule,,,18.41,,,fee schedule,,,19.37,,,fee schedule,,,29.24,,,fee schedule,,,18.99,,,fee schedule,,,51.0,,,percent of total billed charges,,,,,,,,,19.37,,,fee schedule,,,,,,,,,57.80,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,21.32,,,fee schedule,,,18.99,,,fee schedule,,,,,,,,,18.80,,,fee schedule,,,18.99,,,fee schedule,,,,,,,,,19.18,,,fee schedule,,,,,,,,
Prolactin Dilution Study (0020724),10623669,CDM,0300,RC,84146,CPT,398,EAPG,,,,outpatient,facility,,,68.00,20.40,15.65,44.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,37.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,15.65,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,39.06,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,42.97,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
MWH Acquisition,10623678,CDM,0483,RC,93351,CPT,,,,,,outpatient,facility,,,1950.00,585.00,394.40,1657.5,,528.56,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA CARDIAC STUDIES PROC]] 312.26% of Table  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,394.40,,,fee schedule,,,983.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,828.75,,,percent of total billed charges,,,,,,,,,1462.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,975.0,,,percent of total billed charges,,,,,,,,,1462.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1657.5,,,percent of total billed charges,,,897.0,,,percent of total billed charges,,,,,,,,,812.0,,,per diem,,,,,,,,,,,,,,,715.0,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,
MWH Acquisition,10623678,CDM,0483,RC,93351,CPT,05524,APC,,,,outpatient,facility,,,1950.00,585.00,504.34,1207.63,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,1106.10,,,fee schedule,,,504.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",536.32,,,fee schedule,,,1207.63,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,1090.07,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,504.34,,,fee schedule,,,536.32,,,fee schedule,,,,,,,,,525.80,,,fee schedule,,,,,,,,,504.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",536.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.80,,,fee schedule,,,,,,,,,,,,,,,525.80,,,fee schedule,,,,,,,,,531.03,,,fee schedule,,,,,,,,
MWH Acquisition,10623678,CDM,0483,RC,93351,CPT,81,EAPG,,,,outpatient,facility,,,1950.00,585.00,630.02,1789.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1789.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,1520.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,630.02,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,1051.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,1156.67,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SYSTEM CARDIAC REVEAL LINQ II,10623749,CDM,0278,RC,C1764,HCPCS,,,,,,inpatient,facility,,,15883.00,4764.90,6162.60,13500.55,,7782.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6670.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6162.60,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6750.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7941.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13500.55,,,percent of total billed charges,,,7147.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM CARDIAC REVEAL LINQ II,10623749,CDM,0278,RC,C1764,HCPCS,,,,,,outpatient,facility,,,15883.00,4764.90,6670.86,13500.55,,7782.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6670.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8011.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6750.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,11912.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,7941.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11912.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,13500.55,,,percent of total billed charges,,,7306.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL 11X270MM,10623750,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3616.00,1084.80,1403.01,3073.60,,,,,,,,,,,,,,,,,,,,1403.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1536.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2712.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1808.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3073.60,,,percent of total billed charges,,,1627.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL 11X270MM,10623750,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3616.00,1084.80,1536.8,3073.60,,,,,,,,,,,,,service not payable,,,,,,,1823.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1536.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2712.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1808.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2712.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3073.60,,,percent of total billed charges,,,1663.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL TIBIAL 11X285MM,10623751,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3616.00,1084.80,1403.01,3073.60,,,,,,,,,,,,,,,,,,,,1403.01,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1536.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2712.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1808.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3073.60,,,percent of total billed charges,,,1627.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL TIBIAL 11X285MM,10623751,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3616.00,1084.80,1536.8,3073.60,,,,,,,,,,,,,service not payable,,,,,,,1823.91,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1536.8,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2712.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1808.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2712.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3073.60,,,percent of total billed charges,,,1663.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LCKING 5X45MM,10623752,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,749.00,224.70,290.61,636.65,,,,,,,,,,,,,,,,,,,,290.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,561.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,374.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,636.65,,,percent of total billed charges,,,337.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LCKING 5X45MM,10623752,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,749.00,224.70,318.32,636.65,,,,,,,,,,,,,service not payable,,,,,,,377.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,318.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,561.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,374.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,561.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,344.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LCKING 5X60MM,10623753,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,749.00,224.70,290.61,636.65,,,,,,,,,,,,,,,,,,,,290.61,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,561.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,374.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,636.65,,,percent of total billed charges,,,337.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LCKING 5X60MM,10623753,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,749.00,224.70,318.32,636.65,,,,,,,,,,,,,service not payable,,,,,,,377.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,318.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,561.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,374.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,561.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,636.65,,,percent of total billed charges,,,344.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LOCKING ADV 5X50MM,10623754,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,880.00,264.00,341.44,748.0,,,,,,,,,,,,,,,,,,,,341.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.0,,,percent of total billed charges,,,396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LOCKING ADV 5X50MM,10623754,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,880.00,264.00,374.0,748.0,,,,,,,,,,,,,service not payable,,,,,,,443.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,374.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,748.0,,,percent of total billed charges,,,404.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LCKNG ADV 5X57.5MM,10623755,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,880.00,264.00,341.44,748.0,,,,,,,,,,,,,,,,,,,,341.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.0,,,percent of total billed charges,,,396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LCKNG ADV 5X57.5MM,10623755,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,880.00,264.00,374.0,748.0,,,,,,,,,,,,,service not payable,,,,,,,443.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,374.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,748.0,,,percent of total billed charges,,,404.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE LCKNG ADV 5X60MM,10623756,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,880.00,264.00,341.44,748.0,,,,,,,,,,,,,,,,,,,,341.44,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,660.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,440.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.0,,,percent of total billed charges,,,396.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE LCKNG ADV 5X60MM,10623756,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,880.00,264.00,374.0,748.0,,,,,,,,,,,,,service not payable,,,,,,,443.87,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,374.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,660.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,440.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,660.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,748.0,,,percent of total billed charges,,,404.80,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM LPS-FLEX GSF LFT SZ F,10623757,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM LPS-FLEX GSF LFT SZ F,10623757,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW NONLK VAR HEX 4.75X45MM,10623758,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,300.00,90.00,116.40,255.0,,,,,,,,,,,,,,,,,,,,116.40,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.0,,,percent of total billed charges,,,135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW NONLK VAR HEX 4.75X45MM,10623758,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,300.00,90.00,127.5,255.0,,,,,,,,,,,,,service not payable,,,,,,,151.32,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,127.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,225.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,150.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,225.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,255.0,,,percent of total billed charges,,,138.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
WIRE BONE K REC THD 3.2X400MM,10623759,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,531.00,159.30,206.03,451.35,,,,,,,,,,,,,,,,,,,,206.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,398.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,451.35,,,percent of total billed charges,,,238.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WIRE BONE K REC THD 3.2X400MM,10623759,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,531.00,159.30,225.67,451.35,,,,,,,,,,,,,service not payable,,,,,,,267.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,225.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,398.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,265.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,398.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,451.35,,,percent of total billed charges,,,244.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM HIP ECHO OFFSET 7X115MM,10623761,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM HIP ECHO OFFSET 7X115MM,10623761,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL UNI SIGMA SZ 2 RML,10623763,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL UNI SIGMA SZ 2 RML,10623763,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY TIBIAL UNI SIG SZ 2 RMLL,10623764,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4152.00,1245.60,1610.98,3529.20,,,,,,,,,,,,,,,,,,,,1610.98,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3529.20,,,percent of total billed charges,,,1868.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAY TIBIAL UNI SIG SZ 2 RMLL,10623764,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4152.00,1245.60,1764.60,3529.20,,,,,,,,,,,,,service not payable,,,,,,,2094.27,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1764.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3114.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2076.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3114.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3529.20,,,percent of total billed charges,,,1909.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 3.5 DUAL 9H 118,10623765,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 3.5 DUAL 9H 118,10623765,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM SZ9 EXTENDED,10623767,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM SZ9 EXTENDED,10623767,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X80MM,10623768,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X80MM,10623768,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X85MM,10623769,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,657.00,197.10,254.92,558.45,,,,,,,,,,,,,,,,,,,,254.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.45,,,percent of total billed charges,,,295.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X85MM,10623769,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,657.00,197.10,279.22,558.45,,,,,,,,,,,,,service not payable,,,,,,,331.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,279.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,492.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,328.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,492.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,558.45,,,percent of total billed charges,,,302.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 35MM 3HX5H 73MM,10623770,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1695.00,508.50,657.66,1440.75,,,,,,,,,,,,,,,,,,,,657.66,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1440.75,,,percent of total billed charges,,,762.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 35MM 3HX5H 73MM,10623770,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1695.00,508.50,720.38,1440.75,,,,,,,,,,,,,service not payable,,,,,,,854.96,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,720.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1271.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,847.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1271.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1440.75,,,percent of total billed charges,,,779.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ANT CHMBR 5.5X12.5MM 12.5,10623771,CDM,0276,RC,V2630,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ANT CHMBR 5.5X12.5MM 12.5,10623771,CDM,0276,RC,V2630,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CATH GUIDE ECR40 7F 100CM,10623773,CDM,0272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,209.00,62.70,88.83,177.65,,129.16,,,percent of total billed charges,,,,,,,,service not payable,101.99,,,percent of total billed charges,,,105.42,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,88.83,,,percent of total billed charges,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,104.5,,,percent of total billed charges,,,,,,,,service not payable,156.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,177.65,,,percent of total billed charges,,,96.14,,,percent of total billed charges,,,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,135.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETABULAR LL 40X58MM,10623774,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETABULAR LL 40X58MM,10623774,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FEM ACETABULAR LL 58MM,10623775,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3443.00,1032.90,1335.88,2926.55,,,,,,,,,,,,,,,,,,,,1335.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2926.55,,,percent of total billed charges,,,1549.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FEM ACETABULAR LL 58MM,10623775,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3443.00,1032.90,1463.27,2926.55,,,,,,,,,,,,,service not payable,,,,,,,1736.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1463.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2582.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1721.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2582.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2926.55,,,percent of total billed charges,,,1583.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12/14 TAPER 40MM,10623776,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12/14 TAPER 40MM,10623776,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Everolimus Level,10623967,CDM,0300,RC,80169,CPT,,,,,,outpatient,facility,,,102.00,30.60,13.04,86.70,,58.36,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,13.46,,,fee schedule,,,43.55,,,fee schedule,,,28.63,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,28.42,,,fee schedule,,,13.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",13.73,,,fee schedule,,,31.03,,,fee schedule,,,,,,,,,13.46,,,fee schedule,,,,,,,,,17.69,,,fee schedule,,,28.01,,,fee schedule,,,76.5,,,percent of total billed charges,,,13.46,,,fee schedule,,,13.04,,,fee schedule,,,13.73,,,fee schedule,,,20.81,,,fee schedule,,,13.46,,,fee schedule,,,76.5,,,percent of total billed charges,,,,,,,,,13.73,,,fee schedule,,,,,,,,,86.70,,,percent of total billed charges,,,46.92,,,percent of total billed charges,,,,,,,,,15.1,,,fee schedule,,,13.46,,,fee schedule,,,,,,,,,13.32,,,fee schedule,,,13.46,,,fee schedule,,,,,,,,,13.59,,,fee schedule,,,,,,,,
Everolimus Level,10623967,CDM,0300,RC,80169,CPT,405,EAPG,,,,outpatient,facility,,,102.00,30.60,14.30,137.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,116.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,14.30,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,60.76,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,66.84,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
GRAFT VASC GELWEAVE 10MMX30CM,10624187,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1935.00,580.50,750.78,1644.75,,,,,,,,,,,,,,,,,,,,750.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1451.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,967.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1644.75,,,percent of total billed charges,,,870.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VASC GELWEAVE 10MMX30CM,10624187,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1935.00,580.50,822.38,1644.75,,,,,,,,,,,,,service not payable,,,,,,,976.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,822.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1451.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,967.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1451.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1644.75,,,percent of total billed charges,,,890.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT VASC GELWEAVE 12MMX30CM,10624188,CDM,0278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1935.00,580.50,750.78,1644.75,,,,,,,,,,,,,,,,,,,,750.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,822.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1451.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,967.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1644.75,,,percent of total billed charges,,,870.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT VASC GELWEAVE 12MMX30CM,10624188,CDM,0278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1935.00,580.50,822.38,1644.75,,,,,,,,,,,,,service not payable,,,,,,,976.01,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,822.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1451.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,967.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1451.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1644.75,,,percent of total billed charges,,,890.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 50X28MM,10624190,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 50X28MM,10624190,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF 3-5 AB LT 13MM,10624191,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF 3-5 AB LT 13MM,10624191,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 5D SZ B LEFT,10624192,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 5D SZ B LEFT,10624192,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM NAR LEFT SZ 5,10624193,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM NAR LEFT SZ 5,10624193,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT ARCUS 16X13 STAPLE STRL,10624194,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3895.00,1168.50,1511.26,3310.75,,,,,,,,,,,,,,,,,,,,1511.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3310.75,,,percent of total billed charges,,,1752.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT ARCUS 16X13 STAPLE STRL,10624194,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3895.00,1168.50,1655.38,3310.75,,,,,,,,,,,,,service not payable,,,,,,,1964.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3310.75,,,percent of total billed charges,,,1791.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SET STAPLE ARCUS 20X17,10624195,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SET STAPLE ARCUS 20X17,10624195,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT STAPLE ARCUS STERILE 20X17,10624196,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3895.00,1168.50,1511.26,3310.75,,,,,,,,,,,,,,,,,,,,1511.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3310.75,,,percent of total billed charges,,,1752.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT STAPLE ARCUS STERILE 20X17,10624196,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3895.00,1168.50,1655.38,3310.75,,,,,,,,,,,,,service not payable,,,,,,,1964.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1655.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2921.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1947.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2921.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3310.75,,,percent of total billed charges,,,1791.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 4.5X56MM,10624197,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,935.00,280.50,362.78,794.75,,,,,,,,,,,,,,,,,,,,362.78,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,794.75,,,percent of total billed charges,,,420.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 4.5X56MM,10624197,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,935.00,280.50,397.38,794.75,,,,,,,,,,,,,service not payable,,,,,,,471.61,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,397.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,701.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,467.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,701.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,794.75,,,percent of total billed charges,,,430.10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
KIT SIZING ARCUS TEMPLATE,10624198,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT SIZING ARCUS TEMPLATE,10624198,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LVL 1 THORACIC 10H,10624199,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,21869.00,6560.70,8485.17,18588.65,,10715.81,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9184.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8485.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9294.32,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16401.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10934.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18588.65,,,percent of total billed charges,,,9841.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LVL 1 THORACIC 10H,10624199,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,21869.00,6560.70,9184.98,18588.65,,10715.81,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9184.98,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,11030.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9294.32,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16401.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10934.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16401.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18588.65,,,percent of total billed charges,,,10059.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW COMP FT 2.5X32MM,10624200,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW COMP FT 2.5X32MM,10624200,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VPC 3.4X22MM,10624201,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1624.00,487.20,630.11,1380.40,,,,,,,,,,,,,,,,,,,,630.11,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1380.40,,,percent of total billed charges,,,730.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VPC 3.4X22MM,10624201,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1624.00,487.20,690.20,1380.40,,,,,,,,,,,,,service not payable,,,,,,,819.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,690.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1218.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,812.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1218.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1380.40,,,percent of total billed charges,,,747.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LK EVOS ST 2.7X16MM,10624202,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,643.00,192.90,249.48,546.55,,,,,,,,,,,,,,,,,,,,249.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,482.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,321.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,546.55,,,percent of total billed charges,,,289.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LK EVOS ST 2.7X16MM,10624202,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,643.00,192.90,273.27,546.55,,,,,,,,,,,,,service not payable,,,,,,,324.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,273.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,482.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,321.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,482.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,546.55,,,percent of total billed charges,,,295.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LCK 3.5 X 11 T8,10624203,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,776.00,232.80,301.09,659.60,,,,,,,,,,,,,,,,,,,,301.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,329.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,582.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,388.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.60,,,percent of total billed charges,,,349.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LCK 3.5 X 11 T8,10624203,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,776.00,232.80,329.80,659.60,,,,,,,,,,,,,service not payable,,,,,,,391.41,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,329.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,582.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,388.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,582.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,659.60,,,percent of total billed charges,,,356.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP 2.0 X 11MM,10624204,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP 2.0 X 11MM,10624204,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP 2.0 X 12MM,10624205,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP 2.0 X 12MM,10624205,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP 2.0 X 14MM,10624206,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,602.00,180.60,233.58,511.70,,,,,,,,,,,,,,,,,,,,233.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.70,,,percent of total billed charges,,,270.90,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP 2.0 X 14MM,10624206,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,602.00,180.60,255.85,511.70,,,,,,,,,,,,,service not payable,,,,,,,303.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,255.85,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,451.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,301.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,451.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,511.70,,,percent of total billed charges,,,276.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE STRAIGHT 2.0MM 8H,10624207,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3475.00,1042.50,1348.3,2953.75,,,,,,,,,,,,,,,,,,,,1348.3,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.75,,,percent of total billed charges,,,1563.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE STRAIGHT 2.0MM 8H,10624207,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3475.00,1042.50,1476.88,2953.75,,,,,,,,,,,,,service not payable,,,,,,,1752.79,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1476.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2606.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1737.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2606.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2953.75,,,percent of total billed charges,,,1598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2X12MM,10624208,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2X12MM,10624208,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2X13MM,10624209,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2X13MM,10624209,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2X16MM,10624210,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2X16MM,10624210,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW VAL TI 2X18MM,10624211,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,766.00,229.80,297.21,651.10,,,,,,,,,,,,,,,,,,,,297.21,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.10,,,percent of total billed charges,,,344.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW VAL TI 2X18MM,10624211,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,766.00,229.80,325.55,651.10,,,,,,,,,,,,,service not payable,,,,,,,386.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,325.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,574.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,383.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,574.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,651.10,,,percent of total billed charges,,,352.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF PERSONA LT 11MM,10624212,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF PERSONA LT 11MM,10624212,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ6 LT,10624213,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ6 LT,10624213,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE FEM PROX 12H 258MM,10624214,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3778.00,1133.40,1465.86,3211.30,,,,,,,,,,,,,,,,,,,,1465.86,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1605.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2833.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1889.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3211.30,,,percent of total billed charges,,,1700.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE FEM PROX 12H 258MM,10624214,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3778.00,1133.40,1605.65,3211.30,,,,,,,,,,,,,service not payable,,,,,,,1905.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1605.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2833.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1889.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2833.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3211.30,,,percent of total billed charges,,,1737.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X75MM,10624215,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X75MM,10624215,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X100MM,10624216,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X100MM,10624216,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X26MM,10624217,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X26MM,10624217,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X24MM,10624218,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X24MM,10624218,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X44MM,10624219,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X44MM,10624219,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X22MM,10624220,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X22MM,10624220,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT ST 5X40MM,10624221,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT ST 5X40MM,10624221,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE CANN DRILL 7X200MM,10624222,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,520.00,156.00,221.0,442.0,,321.36,,,percent of total billed charges,,,,,,,,service not payable,253.76,,,percent of total billed charges,,,262.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,221.0,,,percent of total billed charges,,,,,,,,,390.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,260.0,,,percent of total billed charges,,,,,,,,service not payable,390.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,442.0,,,percent of total billed charges,,,239.20,,,percent of total billed charges,,,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,338.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY POWERPICC X2LUM 4F,10624223,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1682.00,504.60,714.85,1429.7,,1039.48,,,percent of total billed charges,,,,,,,,service not payable,820.82,,,percent of total billed charges,,,848.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,714.85,,,percent of total billed charges,,,,,,,,,1261.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,841.0,,,percent of total billed charges,,,,,,,,service not payable,1261.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1429.7,,,percent of total billed charges,,,773.72,,,percent of total billed charges,,,,,,,,,1093.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1093.3,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TRAY POWERPICC X1LUM 3F,10624224,CDM,0272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1641.00,492.30,697.42,1394.85,,1014.14,,,percent of total billed charges,,,,,,,,service not payable,800.81,,,percent of total billed charges,,,827.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,697.42,,,percent of total billed charges,,,,,,,,,1230.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,820.5,,,percent of total billed charges,,,,,,,,service not payable,1230.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1394.85,,,percent of total billed charges,,,754.86,,,percent of total billed charges,,,,,,,,,1066.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1066.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT PROXIMAL 20F 2X36X122MM,10624225,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,26270.00,7881.00,10192.76,22329.5,,12872.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,11033.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,10192.76,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11164.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,19702.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13135.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22329.5,,,percent of total billed charges,,,11821.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT PROXIMAL 20F 2X36X122MM,10624225,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,26270.00,7881.00,11033.4,22329.5,,12872.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,11033.4,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,13250.59,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,11164.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,19702.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,13135.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,19702.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,22329.5,,,percent of total billed charges,,,12084.20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW FT COMP STD 4.0X45MM,10624227,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1612.00,483.60,625.46,1370.2,,,,,,,,,,,,,,,,,,,,625.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.2,,,percent of total billed charges,,,725.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW FT COMP STD 4.0X45MM,10624227,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1612.00,483.60,685.10,1370.2,,,,,,,,,,,,,service not payable,,,,,,,813.09,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,685.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1209.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,806.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1209.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1370.2,,,percent of total billed charges,,,741.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W SUPP 0 1 3/4IN,10624819,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPP 0 1 3/4IN,10624819,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W SUPPORT 1 2IN,10624820,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPPORT 1 2IN,10624820,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W SUPP 6 3 1/4IN,10624821,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPP 6 3 1/4IN,10624821,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W SUPP 7 3 1/2IN,10624823,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPP 7 3 1/2IN,10624823,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY GELLHORN SHORT 1 3/4IN,10624826,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY GELLHORN SHORT 1 3/4IN,10624826,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY GELLHORN SHORT 2 1/4IN,10624827,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY GELLHORN SHORT 2 1/4IN,10624827,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY GELLHORN SHORT 3 1/4IN,10624828,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY GELLHORN SHORT 3 1/4IN,10624828,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY GELLHORN SHORT 3 1/2IN,10624829,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY GELLHORN SHORT 3 1/2IN,10624829,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY GELLHORN SHORT 3 3/4IN,10624830,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY GELLHORN SHORT 3 3/4IN,10624830,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY RING W SUPP 4 2 3/4IN,10624831,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY RING W SUPP 4 2 3/4IN,10624831,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PESSARY DISH INCONTINENCE SZ 2,10624832,CDM,0278,RC,A4561,HCPCS,,,,,,inpatient,facility,,,227.00,68.10,88.08,192.95,,,,,,,,,,,,,,,,,,,,88.08,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.95,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PESSARY DISH INCONTINENCE SZ 2,10624832,CDM,0278,RC,A4561,HCPCS,,,,,,outpatient,facility,,,227.00,68.10,96.47,192.95,,,,,,,,,,,,,service not payable,,,,,,,114.5,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,96.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,170.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,113.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,170.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,192.95,,,percent of total billed charges,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIA REV PSN LT SZC,10624833,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8360.00,2508.00,3243.68,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3243.68,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7106.0,,,percent of total billed charges,,,3762.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIA REV PSN LT SZC,10624833,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8360.00,2508.00,3511.20,7106.0,,4096.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3511.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4216.78,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3553.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6270.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4180.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6270.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,7106.0,,,percent of total billed charges,,,3845.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
TIBIAL AUG REV PSN SZCD LT 5MM,10624834,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIBIAL AUG REV PSN SZCD LT 5MM,10624834,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EXT REV PSN 10X135MM,10624835,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5655.00,1696.50,2194.14,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2194.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4806.75,,,percent of total billed charges,,,2544.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EXT REV PSN 10X135MM,10624835,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5655.00,1696.50,2375.10,4806.75,,2770.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2375.10,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2852.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2403.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4241.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2827.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4241.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4806.75,,,percent of total billed charges,,,2601.30,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM POST REV SZ5 10MM,10624836,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM POST REV SZ5 10MM,10624836,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
AUGMENT FEM DIST REV SZ5 10MM,10624837,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3607.00,1082.10,1399.52,3065.95,,,,,,,,,,,,,,,,,,,,1399.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3065.95,,,percent of total billed charges,,,1623.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AUGMENT FEM DIST REV SZ5 10MM,10624837,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3607.00,1082.10,1532.97,3065.95,,,,,,,,,,,,,service not payable,,,,,,,1819.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1532.97,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2705.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1803.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2705.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3065.95,,,percent of total billed charges,,,1659.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF PERS LT 18MM 3-5,10624838,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF PERS LT 18MM 3-5,10624838,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 2.7MM DUAL LCK 16H 18MM,10624839,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2132.00,639.60,827.22,1812.2,,,,,,,,,,,,,,,,,,,,827.22,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.2,,,percent of total billed charges,,,959.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 2.7MM DUAL LCK 16H 18MM,10624839,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2132.00,639.60,906.10,1812.2,,,,,,,,,,,,,service not payable,,,,,,,1075.38,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,906.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1599.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1066.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1599.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1812.2,,,percent of total billed charges,,,980.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SUT PEEK QUATTRO 4.5MM,10624840,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1776.00,532.80,689.09,1509.60,,,,,,,,,,,,,,,,,,,,689.09,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.60,,,percent of total billed charges,,,799.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SUT PEEK QUATTRO 4.5MM,10624840,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1776.00,532.80,754.80,1509.60,,,,,,,,,,,,,service not payable,,,,,,,895.81,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,754.80,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1332.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,888.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1332.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1509.60,,,percent of total billed charges,,,816.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BROACH ARCOS SZ A STD 60MM,10624842,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20554.00,6166.20,7974.95,17470.90,,10071.46,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8632.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7974.95,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8735.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15415.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10277.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17470.90,,,percent of total billed charges,,,9249.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BROACH ARCOS SZ A STD 60MM,10624842,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20554.00,6166.20,8632.68,17470.90,,10071.46,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8632.68,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10367.44,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8735.45,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15415.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10277.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15415.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17470.90,,,percent of total billed charges,,,9454.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM STEM ARCOS 12X190MM,10624843,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11212.00,3363.60,4350.26,9530.20,,5493.88,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4709.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4350.26,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4765.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8409.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5606.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9530.20,,,percent of total billed charges,,,5045.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM STEM ARCOS 12X190MM,10624843,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11212.00,3363.60,4709.04,9530.20,,5493.88,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4709.04,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5655.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4765.10,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8409.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5606.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8409.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9530.20,,,percent of total billed charges,,,5157.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CUP ACETABULAR RINGLOC 42X28MM,10624844,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3426.00,1027.80,1329.29,2912.10,,,,,,,,,,,,,,,,,,,,1329.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2912.10,,,percent of total billed charges,,,1541.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CUP ACETABULAR RINGLOC 42X28MM,10624844,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3426.00,1027.80,1456.05,2912.10,,,,,,,,,,,,,service not payable,,,,,,,1728.07,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1456.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2569.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1713.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2569.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2912.10,,,percent of total billed charges,,,1575.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GUIDEWIRE BEAD TIP 2.6MMX80CM,10624845,CDM,0272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,614.00,184.20,260.95,521.90,,379.45,,,percent of total billed charges,,,,,,,,service not payable,299.63,,,percent of total billed charges,,,309.70,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,260.95,,,percent of total billed charges,,,,,,,,,460.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,307.0,,,percent of total billed charges,,,,,,,,service not payable,460.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,521.90,,,percent of total billed charges,,,282.44,,,percent of total billed charges,,,,,,,,,399.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,399.10,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW PL 3.5X60MM,10624846,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,574.00,172.20,222.71,487.90,,,,,,,,,,,,,,,,,,,,222.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.90,,,percent of total billed charges,,,258.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW PL 3.5X60MM,10624846,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,574.00,172.20,243.95,487.90,,,,,,,,,,,,,service not payable,,,,,,,289.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,243.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,430.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,287.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,430.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,487.90,,,percent of total billed charges,,,264.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE PROX LAT LK 3.5MM 8H LT,10624847,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3901.00,1170.30,1513.59,3315.85,,,,,,,,,,,,,,,,,,,,1513.59,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1657.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2925.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1950.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3315.85,,,percent of total billed charges,,,1755.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE PROX LAT LK 3.5MM 8H LT,10624847,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3901.00,1170.30,1657.92,3315.85,,,,,,,,,,,,,service not payable,,,,,,,1967.66,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1657.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2925.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1950.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2925.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3315.85,,,percent of total billed charges,,,1794.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3.5X34MM PART THD,10624848,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,861.00,258.30,334.07,731.85,,,,,,,,,,,,,,,,,,,,334.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.85,,,percent of total billed charges,,,387.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3.5X34MM PART THD,10624848,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,861.00,258.30,365.93,731.85,,,,,,,,,,,,,service not payable,,,,,,,434.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,645.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,396.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 3.5X40MM PARTIAL TH,10624849,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,861.00,258.30,334.07,731.85,,,,,,,,,,,,,,,,,,,,334.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.85,,,percent of total billed charges,,,387.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 3.5X40MM PARTIAL TH,10624849,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,861.00,258.30,365.93,731.85,,,,,,,,,,,,,service not payable,,,,,,,434.29,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,365.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,645.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,430.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,645.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,731.85,,,percent of total billed charges,,,396.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM CCD 13MMX38CM,10624850,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5706.00,1711.80,2213.93,4850.10,,2795.94,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2396.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2213.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2425.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4279.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2853.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4850.10,,,percent of total billed charges,,,2567.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM CCD 13MMX38CM,10624850,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5706.00,1711.80,2396.52,4850.10,,2795.94,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2396.52,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2878.11,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2425.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4279.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2853.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4279.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4850.10,,,percent of total billed charges,,,2624.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 LNGVT 32MM SZE,10627172,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 LNGVT 32MM SZE,10627172,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM LATERAL 4 TAPER 12/14,10627173,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4918.00,1475.40,1908.18,4180.30,,,,,,,,,,,,,,,,,,,,1908.18,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4180.30,,,percent of total billed charges,,,2213.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM LATERAL 4 TAPER 12/14,10627173,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4918.00,1475.40,2090.15,4180.30,,,,,,,,,,,,,service not payable,,,,,,,2480.64,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2090.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3688.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2459.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3688.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4180.30,,,percent of total billed charges,,,2262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL FEM 13MMX34CM 125D RT,10627174,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5711.00,1713.30,2215.87,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2215.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4854.35,,,percent of total billed charges,,,2569.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL FEM 13MMX34CM 125D RT,10627174,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5711.00,1713.30,2398.62,4854.35,,2798.39,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2398.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2880.63,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2427.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4283.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2855.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4283.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4854.35,,,percent of total billed charges,,,2627.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB BEARING SZ3 16MM,10627175,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB BEARING SZ3 16MM,10627175,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS IQ TORIC 5.25D 18.5,10627176,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,2704.00,811.20,1049.15,2298.40,,,,,,,,,,,,,,,,,,,,1049.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2298.40,,,percent of total billed charges,,,1216.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS IQ TORIC 5.25D 18.5,10627176,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,2704.00,811.20,1149.2,2298.40,,,,,,,,,,,,,service not payable,,,,,,,1363.90,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1149.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2028.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1352.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2028.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2298.40,,,percent of total billed charges,,,1243.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE CAN LOK LP 40X3.5MM,10627317,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,465.00,139.50,180.42,395.25,,,,,,,,,,,,,,,,,,,,180.42,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE CAN LOK LP 40X3.5MM,10627317,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,465.00,139.50,197.62,395.25,,,,,,,,,,,,,service not payable,,,,,,,234.55,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,197.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,348.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,232.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,348.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,395.25,,,percent of total billed charges,,,213.90,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SURELOCK 2.2MM FLEX,10627322,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1558.00,467.40,604.50,1324.3,,,,,,,,,,,,,,,,,,,,604.50,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1168.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,779.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1324.3,,,percent of total billed charges,,,701.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SURELOCK 2.2MM FLEX,10627322,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1558.00,467.40,662.15,1324.3,,,,,,,,,,,,,service not payable,,,,,,,785.86,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,662.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1168.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,779.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1168.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1324.3,,,percent of total billed charges,,,716.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM REV 20X265MM,10627324,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,20260.00,6078.00,7860.88,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,7860.88,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17221.0,,,percent of total billed charges,,,9117.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM REV 20X265MM,10627324,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,20260.00,6078.00,8509.20,17221.0,,9927.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8509.20,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10219.14,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,8610.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,15195.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10130.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,15195.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,17221.0,,,percent of total billed charges,,,9319.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE HUMERUS PROX LT 4H 83MM,10627325,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4147.00,1244.10,1609.04,3524.95,,,,,,,,,,,,,,,,,,,,1609.04,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1762.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3110.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2073.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3524.95,,,percent of total billed charges,,,1866.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE HUMERUS PROX LT 4H 83MM,10627325,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4147.00,1244.10,1762.47,3524.95,,,,,,,,,,,,,service not payable,,,,,,,2091.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1762.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3110.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2073.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3110.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3524.95,,,percent of total billed charges,,,1907.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CORT LP NL NS 3.5X36MM,10627326,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,295.00,88.50,114.46,250.75,,,,,,,,,,,,,,,,,,,,114.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,221.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.75,,,percent of total billed charges,,,132.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CORT LP NL NS 3.5X36MM,10627326,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,295.00,88.50,125.38,250.75,,,,,,,,,,,,,service not payable,,,,,,,148.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,125.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,221.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,221.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,250.75,,,percent of total billed charges,,,135.70,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW T15 MD LOCKING 3.5X40MM,10627327,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,864.00,259.20,335.23,734.40,,,,,,,,,,,,,,,,,,,,335.23,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,648.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,432.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734.40,,,percent of total billed charges,,,388.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW T15 MD LOCKING 3.5X40MM,10627327,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,864.00,259.20,367.20,734.40,,,,,,,,,,,,,service not payable,,,,,,,435.80,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,367.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,648.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,432.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,648.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,734.40,,,percent of total billed charges,,,397.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CAGE EXPAND 10MM 10X24MM 6D,10627328,CDM,0278,RC,C1821,HCPCS,,,,,,inpatient,facility,,,16392.00,4917.60,6360.10,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6360.10,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.20,,,percent of total billed charges,,,7376.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAGE EXPAND 10MM 10X24MM 6D,10627328,CDM,0278,RC,C1821,HCPCS,,,,,,outpatient,facility,,,16392.00,4917.60,6884.64,13933.20,,8032.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6884.64,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,8268.12,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8196.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,12294.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13933.20,,,percent of total billed charges,,,7540.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT HUMAN TIS 80MG AMNIOBAND,10627329,CDM,0278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4848.00,1454.40,1881.02,4120.80,,,,,,,,,,,,,,,,,,,,1881.02,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2060.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3636.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2424.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4120.80,,,percent of total billed charges,,,2181.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT HUMAN TIS 80MG AMNIOBAND,10627329,CDM,0278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4848.00,1454.40,2060.40,4120.80,,,,,,,,,,,,,service not payable,,,,,,,2445.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2060.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3636.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2424.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3636.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4120.80,,,percent of total billed charges,,,2230.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTICULAR PSN RT 11MM,10627330,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTICULAR PSN RT 11MM,10627330,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X38MM,10627331,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X38MM,10627331,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X40MM,10627332,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X40MM,10627332,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X42MM,10627333,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X42MM,10627333,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X46MM,10627334,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X46MM,10627334,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X48MM,10627335,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X48MM,10627335,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X50MM,10627336,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X50MM,10627336,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X52MM,10627337,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X52MM,10627337,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X54MM,10627338,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X54MM,10627338,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X56MM,10627339,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X56MM,10627339,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X58MM,10627340,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X58MM,10627340,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ACT ARTIC HD ARCOM XL 28X60MM,10627341,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACT ARTIC HD ARCOM XL 28X60MM,10627341,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X42MM,10627342,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X42MM,10627342,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X46MM,10627343,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X46MM,10627343,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X48MM,10627344,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X48MM,10627344,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X50MM,10627345,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X50MM,10627345,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X52MM,10627346,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X52MM,10627346,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X54MM,10627347,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X54MM,10627347,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X58MM,10627348,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X58MM,10627348,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BEARING ACTIVE ARTIC 28X60MM,10627349,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEARING ACTIVE ARTIC 28X60MM,10627349,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 28/3MM T1,10627350,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 28/3MM T1,10627350,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 28/0MM T1,10627351,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 28/0MM T1,10627351,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 28/-3MM T1,10627352,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 28/-3MM T1,10627352,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 32/6MM T1,10627353,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 32/6MM T1,10627353,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 32/3MM T1,10627354,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 32/3MM T1,10627354,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 32/0MM T1,10627355,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 32/0MM T1,10627355,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD DELTA CER FEM 32/-3MM T1,10627356,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD DELTA CER FEM 32/-3MM T1,10627356,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD SLEEVE FEM TI TYPE1 44MM,10627357,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD SLEEVE FEM TI TYPE1 44MM,10627357,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TYPE 1 MINUS 3.0MM,10627358,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TYPE 1 MINUS 3.0MM,10627358,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TRP 12/14 STD,10627359,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TRP 12/14 STD,10627359,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TRP 12/14 4MM,10627360,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TRP 12/14 4MM,10627360,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SLEEVE FEM TRP 12/14 7MM,10627361,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,546.00,163.80,211.85,464.10,,,,,,,,,,,,,,,,,,,,211.85,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.10,,,percent of total billed charges,,,245.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE FEM TRP 12/14 7MM,10627361,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,546.00,163.80,232.05,464.10,,,,,,,,,,,,,service not payable,,,,,,,275.40,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,232.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,409.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,273.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,409.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,464.10,,,percent of total billed charges,,,251.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ALL-POLY PATELLA 41MM,10627362,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ALL-POLY PATELLA 41MM,10627362,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM DELTA CERAMIC 36/-3MM,10627363,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM DELTA CERAMIC 36/-3MM,10627363,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM DELTA CERAMIC 36/0MM,10627364,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM DELTA CERAMIC 36/0MM,10627364,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM DELTA CERAMIC 36/3MM,10627365,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM DELTA CERAMIC 36/3MM,10627365,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM DELTA CERAMIC 36/6MM,10627366,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM DELTA CERAMIC 36/6MM,10627366,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PATELLA KNEE CEMENTED 26X 8MM,10627367,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1639.00,491.70,635.93,1393.15,,,,,,,,,,,,,,,,,,,,635.93,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.15,,,percent of total billed charges,,,737.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PATELLA KNEE CEMENTED 26X 8MM,10627367,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1639.00,491.70,696.57,1393.15,,,,,,,,,,,,,service not payable,,,,,,,826.71,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,696.57,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1229.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,819.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1229.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1393.15,,,percent of total billed charges,,,753.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA PKS 5DEG L SZ J,10627368,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA PKS 5DEG L SZ J,10627368,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA PKS 5DEG R SZ J,10627369,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3061.00,918.30,1187.67,2601.85,,,,,,,,,,,,,,,,,,,,1187.67,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.85,,,percent of total billed charges,,,1377.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA PKS 5DEG R SZ J,10627369,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3061.00,918.30,1300.92,2601.85,,,,,,,,,,,,,service not payable,,,,,,,1543.97,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1300.92,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2295.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1530.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2295.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2601.85,,,percent of total billed charges,,,1408.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 38MM,10627370,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 38MM,10627370,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 39MM,10627371,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 39MM,10627371,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 40MM,10627372,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 40MM,10627372,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 41MM,10627373,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 41MM,10627373,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 42MM,10627374,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 42MM,10627374,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 45MM,10627375,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 45MM,10627375,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 47MM,10627376,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 47MM,10627376,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 48MM,10627377,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 48MM,10627377,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 49MM,10627378,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 49MM,10627378,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 50MM,10627379,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 50MM,10627379,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 51MM,10627380,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 51MM,10627380,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 52MM,10627381,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 52MM,10627381,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 53MM,10627382,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 53MM,10627382,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ALPS HUM PROX 197MM 11H,10627384,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5414.00,1624.20,2100.63,4601.90,,2652.86,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2273.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2100.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2300.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4060.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2707.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4601.90,,,percent of total billed charges,,,2436.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ALPS HUM PROX 197MM 11H,10627384,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5414.00,1624.20,2273.88,4601.90,,2652.86,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2273.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2730.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2300.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4060.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2707.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4060.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4601.90,,,percent of total billed charges,,,2490.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 54MM,10627385,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 54MM,10627385,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 55MM,10627386,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 55MM,10627386,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 57MM,10627387,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 57MM,10627387,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 60MM,10627388,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 60MM,10627388,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM ENDO 12/14 63MM,10627389,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2295.00,688.50,890.46,1950.75,,,,,,,,,,,,,,,,,,,,890.46,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,,1032.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM ENDO 12/14 63MM,10627389,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2295.00,688.50,975.38,1950.75,,,,,,,,,,,,,service not payable,,,,,,,1157.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,975.38,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1721.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1147.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1721.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,,1055.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADPT HEAD FEM ENDO 12/14 7MM,10627390,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADPT HEAD FEM ENDO 12/14 7MM,10627390,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADPT HEAD FEM ENDO 12/14 10.5,10627391,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADPT HEAD FEM ENDO 12/14 10.5,10627391,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADPT HEAD FEM ENDO 12/14 14MM,10627392,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,984.00,295.20,381.79,836.40,,,,,,,,,,,,,,,,,,,,381.79,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.40,,,percent of total billed charges,,,442.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADPT HEAD FEM ENDO 12/14 14MM,10627392,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,984.00,295.20,418.20,836.40,,,,,,,,,,,,,service not payable,,,,,,,496.33,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,418.20,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,738.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,492.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,738.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,836.40,,,percent of total billed charges,,,452.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 28MM -3.5,10627393,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 28MM -3.5,10627393,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM VRS 12/14 28MM 0,10627394,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM VRS 12/14 28MM 0,10627394,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 28MM 3.5,10627395,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 28MM 3.5,10627395,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 28MM 10.5,10627396,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 28MM 10.5,10627396,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 28MM 7,10627397,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 28MM 7,10627397,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 32MM 3.5,10627398,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 32MM 3.5,10627398,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 32MM 10.5,10627399,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 32MM 10.5,10627399,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 32MM 7,10627400,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 32MM 7,10627400,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA PKS 5DEG R SZA,10627401,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2631.00,789.30,1020.83,2236.35,,,,,,,,,,,,,,,,,,,,1020.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1118.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1973.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2236.35,,,percent of total billed charges,,,1183.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA PKS 5DEG R SZA,10627401,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2631.00,789.30,1118.18,2236.35,,,,,,,,,,,,,service not payable,,,,,,,1327.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1118.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1973.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1973.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2236.35,,,percent of total billed charges,,,1210.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 36MM 10.5,10627402,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 36MM 10.5,10627402,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIBIA PKS 5DEG L SZA,10627403,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2631.00,789.30,1020.83,2236.35,,,,,,,,,,,,,,,,,,,,1020.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1118.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1973.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1315.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2236.35,,,percent of total billed charges,,,1183.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIBIA PKS 5DEG L SZA,10627403,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2631.00,789.30,1118.18,2236.35,,,,,,,,,,,,,service not payable,,,,,,,1327.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1118.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1973.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1315.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1973.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2236.35,,,percent of total billed charges,,,1210.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED LT SZ C,10627404,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED LT SZ C,10627404,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 40MM -3.5,10627405,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 40MM -3.5,10627405,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED RT SZ C,10627406,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED RT SZ C,10627406,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED LT SZ D,10627407,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED LT SZ D,10627407,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 40MM 0,10627408,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 40MM 0,10627408,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED RT SZ D,10627409,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED RT SZ D,10627409,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 40MM 3.5,10627410,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 40MM 3.5,10627410,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 40MM 7,10627411,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 40MM 7,10627411,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 40MM 10.5,10627412,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 40MM 10.5,10627412,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED LT SZ F,10627413,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED LT SZ F,10627413,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED RT SZ F,10627414,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED RT SZ F,10627414,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB BEARING RT SZ G,10627415,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB BEARING RT SZ G,10627415,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 28MM 0,10627416,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 28MM 0,10627416,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP PERSONA TIBIA RT SZ H,10627417,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP PERSONA TIBIA RT SZ H,10627417,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 28MM 3.5,10627418,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 28MM 3.5,10627418,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED LT SZ J,10627419,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED LT SZ J,10627419,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP TIB KNEE 2PED RT SZ J,10627420,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP TIB KNEE 2PED RT SZ J,10627420,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 32MM -3.5,10627421,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 32MM -3.5,10627421,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 32MM 0,10627422,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 32MM 0,10627422,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 32MM 3.5,10627423,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 32MM 3.5,10627423,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 32MM 7,10627424,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 32MM 7,10627424,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 40MM -3.5,10627425,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 40MM -3.5,10627425,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM BIOLOX DEL 40MM 7,10627426,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM BIOLOX DEL 40MM 7,10627426,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 10MM LT,10627427,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 10MM LT,10627427,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 12MM LT,10627428,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 12MM LT,10627428,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 14MM LT,10627429,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 14MM LT,10627429,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 16MM LT,10627430,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 16MM LT,10627430,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 18MM LT,10627431,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 18MM LT,10627431,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SURFACE ARTIC PSN 20MM LT,10627432,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURFACE ARTIC PSN 20MM LT,10627432,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV CD 12MM L,10627433,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV CD 12MM L,10627433,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV CD 14MM L,10627434,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV CD 14MM L,10627434,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV CD 16MM L,10627435,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV CD 16MM L,10627435,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV CD 18MM L,10627436,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV CD 18MM L,10627436,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV CD 20MM L,10627437,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV CD 20MM L,10627437,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV EF 10MM L,10627438,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV EF 10MM L,10627438,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV EF 12MM L,10627439,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV EF 12MM L,10627439,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV EF 14MM L,10627440,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV EF 14MM L,10627440,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV EF 16MM L,10627441,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV EF 16MM L,10627441,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV EF 18MM L,10627442,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV EF 18MM L,10627442,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SRF PSN VIV EF 20MM L,10627443,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3759.00,1127.70,1458.49,3195.15,,,,,,,,,,,,,,,,,,,,1458.49,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3195.15,,,percent of total billed charges,,,1691.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SRF PSN VIV EF 20MM L,10627443,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3759.00,1127.70,1597.58,3195.15,,,,,,,,,,,,,service not payable,,,,,,,1896.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1597.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2819.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2819.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3195.15,,,percent of total billed charges,,,1729.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEMUR PSN SZ4 RT,10627444,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEMUR PSN SZ4 RT,10627444,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 PPS LTD 42A,10627445,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 PPS LTD 42A,10627445,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 PPS LTD 44A,10627446,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 PPS LTD 44A,10627446,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 PPS LTD 46B,10627447,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 PPS LTD 46B,10627447,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 PPS LTD 64H,10627449,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 PPS LTD 64H,10627449,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 PPS LTD 66I,10627450,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 PPS LTD 66I,10627450,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACET G7 PPS LTD 68I,10627451,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACET G7 PPS LTD 68I,10627451,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LENS ACRYSOF UV-ABSRB ASP 27.5,10627452,CDM,0276,RC,V2632,HCPCS,,,,,,inpatient,facility,,,814.00,244.20,315.83,691.90,,,,,,,,,,,,,,,,,,,,315.83,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.90,,,percent of total billed charges,,,366.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LENS ACRYSOF UV-ABSRB ASP 27.5,10627452,CDM,0276,RC,V2632,HCPCS,,,,,,outpatient,facility,,,814.00,244.20,345.95,691.90,,,,,,,,,,,,,service not payable,,,,,,,410.58,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,345.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,610.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,407.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,610.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,691.90,,,percent of total billed charges,,,374.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 12/14 TPR 32MM 7.0MM,10627454,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 12/14 TPR 32MM 7.0MM,10627454,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM A,10628210,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM A,10628210,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM B,10628212,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM B,10628212,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM C,10628213,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM C,10628213,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM D,10628214,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM D,10628214,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM E,10628215,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM E,10628215,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM F,10628216,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM F,10628216,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM G,10628217,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM G,10628217,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 28MM H,10628218,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 28MM H,10628218,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM B,10628220,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM B,10628220,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM C,10628221,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM C,10628221,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM D,10628222,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM D,10628222,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM E,10628223,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM E,10628223,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM F,10628224,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM F,10628224,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM G,10628225,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM G,10628225,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM H,10628226,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM H,10628226,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 32MM I,10628227,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 32MM I,10628227,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 36MM D,10628228,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 36MM D,10628228,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 36MM G,10628229,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 36MM G,10628229,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 36MM H,10628230,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 36MM H,10628230,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 36MM I,10628231,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 36MM I,10628231,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 36MM J,10628232,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 36MM J,10628232,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 40MM H,10628233,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 40MM H,10628233,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 40MM I,10628234,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 40MM I,10628234,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 40MM J,10628235,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 40MM J,10628235,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 44MM H,10628236,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 44MM H,10628236,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 44MM I,10628237,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 44MM I,10628237,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUT ARCOMXL 44MM J,10628238,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUT ARCOMXL 44MM J,10628238,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 28MM A,10628239,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 28MM A,10628239,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 28MM B,10628240,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 28MM B,10628240,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 28MM C,10628241,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 28MM C,10628241,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 28MM D,10628242,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 28MM D,10628242,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 28MM E,10628243,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 28MM E,10628243,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 28MM F,10628244,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 28MM F,10628244,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM B,10628248,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2448.00,734.40,949.82,2080.80,,,,,,,,,,,,,,,,,,,,949.82,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2080.80,,,percent of total billed charges,,,1101.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM B,10628248,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2448.00,734.40,1040.40,2080.80,,,,,,,,,,,,,service not payable,,,,,,,1234.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1040.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1836.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1224.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1836.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2080.80,,,percent of total billed charges,,,1126.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM C,10628249,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM C,10628249,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM D,10628250,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM D,10628250,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM E,10628251,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM E,10628251,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM F,10628252,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM F,10628252,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM G,10628253,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM G,10628253,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM H,10628254,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM H,10628254,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 32MM I,10628255,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 32MM I,10628255,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM D,10628256,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM D,10628256,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM E,10628257,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM E,10628257,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM F,10628258,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM F,10628258,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM G,10628259,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM G,10628259,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM H,10628260,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM H,10628260,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM I,10628261,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM I,10628261,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 36MM J,10628262,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 36MM J,10628262,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 40MM F,10628263,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 40MM F,10628263,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 40MM G,10628264,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 40MM G,10628264,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 40MM H,10628265,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 40MM H,10628265,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 40MM I,10628266,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 40MM I,10628266,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 40MM J,10628267,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 40MM J,10628267,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 44MM H,10628268,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 44MM H,10628268,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 44MM I,10628269,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 44MM I,10628269,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG ARCOMXL 44MM J,10628270,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG ARCOMXL 44MM J,10628270,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM A,10628271,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM A,10628271,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM B,10628272,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM B,10628272,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM C,10628273,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM C,10628273,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM D,10628274,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM D,10628274,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM E,10628275,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM E,10628275,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM F,10628276,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM F,10628276,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM G,10628277,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 28MM G,10628277,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM B,10628279,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM B,10628279,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM C,10628280,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM C,10628280,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM D,10628281,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM D,10628281,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM E,10628282,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM E,10628282,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM F,10628283,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM F,10628283,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM G,10628284,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM G,10628284,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM H,10628285,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM H,10628285,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM I,10628286,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 32MM I,10628286,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM D,10628287,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM D,10628287,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM E,10628288,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM E,10628288,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM F,10628289,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM F,10628289,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM G,10628290,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM G,10628290,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM H,10628291,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM H,10628291,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM I,10628292,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM I,10628292,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM J,10628293,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 36MM J,10628293,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM F,10628294,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM F,10628294,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM G,10628295,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM G,10628295,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM H,10628296,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM H,10628296,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM I,10628297,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM I,10628297,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM J,10628298,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 40MM J,10628298,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 44MM H,10628299,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 44MM H,10628299,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 44MM I,10628300,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 44MM I,10628300,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 HI-WAL ARCOMXL 44MM J,10628301,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 HI-WAL ARCOMXL 44MM J,10628301,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM A,10628302,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM A,10628302,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM B,10628303,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM B,10628303,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM C,10628304,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM C,10628304,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM D,10628305,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM D,10628305,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM E,10628306,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM E,10628306,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM F,10628307,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM F,10628307,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 28MM G,10628308,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 28MM G,10628308,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM B,10628310,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM B,10628310,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM C,10628311,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM C,10628311,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM D,10628312,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM D,10628312,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM E,10628313,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM E,10628313,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM F,10628314,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM F,10628314,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM G,10628315,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM G,10628315,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 32MM H,10628316,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 32MM H,10628316,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 36MM E,10628317,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 36MM E,10628317,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 36MM F,10628318,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 36MM F,10628318,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 36MM G,10628319,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 36MM G,10628319,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 36MM H,10628320,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 36MM H,10628320,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 36MM I,10628321,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 36MM I,10628321,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 36MM J,10628322,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 36MM J,10628322,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 40MM F,10628323,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 40MM F,10628323,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 40MM G,10628324,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 40MM G,10628324,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 40MM H,10628325,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 40MM H,10628325,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 40MM I,10628326,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 40MM I,10628326,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 40MM J,10628327,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 40MM J,10628327,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 44MM H,10628328,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 44MM H,10628328,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 44MM I,10628329,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 44MM I,10628329,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 NEUTRAL E1 44MM J,10628330,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 NEUTRAL E1 44MM J,10628330,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM A,10628331,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM A,10628331,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM B,10628332,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM B,10628332,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM C,10628333,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM C,10628333,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM D,10628334,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM D,10628334,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM E,10628335,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM E,10628335,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM F,10628336,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM F,10628336,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM G,10628337,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM G,10628337,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 28MM H,10628338,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 28MM H,10628338,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM B,10628339,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM B,10628339,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM C,10628340,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM C,10628340,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM D,10628341,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM D,10628341,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM E,10628342,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM E,10628342,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM F,10628343,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM F,10628343,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM G,10628344,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM G,10628344,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 32MM H,10628345,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 32MM H,10628345,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 36MM D,10628346,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM D,10628346,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 36MM E,10628347,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM E,10628347,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW CANN 32MM 6.5X75MM,10628348,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1107.00,332.10,429.52,940.95,,,,,,,,,,,,,,,,,,,,429.52,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.47,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,830.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,553.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,940.95,,,percent of total billed charges,,,498.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW CANN 32MM 6.5X75MM,10628348,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1107.00,332.10,470.47,940.95,,,,,,,,,,,,,service not payable,,,,,,,558.37,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,470.47,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,830.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,553.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,830.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,940.95,,,percent of total billed charges,,,509.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Insert intravascular vena cava filter,10629093,CDM,0481,RC,37191,CPT,,,,,,outpatient,facility,,,11853.00,3555.90,4917.20,12795.0,,6408.55,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",other,,"Procedure Lookup:  Procedure Code Tables:   [[AETNA GROUPER 1]] $3,795.64   [[AETNA GROUPER 2]] $4,778.89   [[AETNA GROUPER 3]] $6,408.55   [[AETNA GROUPER 4]] $7,120.36   [[AETNA GROUPER 5]] $7,943.37   [[AETNA GROUPER 6]] $10,255.42   [[AETNA GROUPER 7]] $11,611.47   [[AETNA GROUPER 8]] $11,668.15   [[AETNA GROUPER 9]] $11,923.23   [[AETNA GROUPER DEFAULT]] $7,119.04  Multipliers: 100%, 50%, 25%  Sort By: Allowed Amount  Conditions:   Process Daily: Y   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: Version 2   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ",,,,,,,4917.20,,,case rate,,,5978.65,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10876.0,,,case rate,,,,,,,,,8889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12795.0,,,case rate,,,,,,,,,8889.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10075.05,,,percent of total billed charges,,,5452.38,,,percent of total billed charges,,,,,,,,,8220.0,,,case rate,,,,,,,,,,,,,,,7234.0,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,
Insert intravascular vena cava filter,10629093,CDM,0481,RC,37191,CPT,05184,APC,,,,outpatient,facility,,,11853.00,3555.90,4972.31,11906.09,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10905.13,,,fee schedule,,,4972.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",5287.57,,,fee schedule,,,11906.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,10747.09,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,4972.31,,,fee schedule,,,5287.57,,,fee schedule,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,4972.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",5287.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,,,,,,,5183.89,,,fee schedule,,,,,,,,,5235.52,,,fee schedule,,,,,,,,
Insert intravascular vena cava filter,10629093,CDM,0481,RC,37191,CPT,77,EAPG,,,,outpatient,facility,,,11853.00,3555.90,5360.09,12010.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12010.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,10209.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,5360.09,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,6296.10,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,6925.71,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
LINER G7 10 DEG E1 36MM F,10629096,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM F,10629096,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 36MM G,10629097,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM G,10629097,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 36MM H,10629098,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM H,10629098,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 36MM I,10629099,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM I,10629099,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 36MM J,10629100,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 36MM J,10629100,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 40MM F,10629101,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 40MM F,10629101,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 40MM G,10629102,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 40MM G,10629102,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 40MM H,10629103,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 40MM H,10629103,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 40MM I,10629104,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 40MM I,10629104,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 40MM J,10629105,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 40MM J,10629105,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 44MM H,10629106,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 44MM H,10629106,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 44MM I,10629107,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 44MM I,10629107,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 10 DEG E1 44MM J,10629108,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 10 DEG E1 44MM J,10629108,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE ANT CERV LVL 1 24MM,10629109,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2323.00,696.90,901.32,1974.55,,,,,,,,,,,,,,,,,,,,901.32,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1974.55,,,percent of total billed charges,,,1045.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE ANT CERV LVL 1 24MM,10629109,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2323.00,696.90,987.27,1974.55,,,,,,,,,,,,,service not payable,,,,,,,1171.72,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,987.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1742.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1161.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1742.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1974.55,,,percent of total billed charges,,,1068.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
CONE ARCOS REV SZB 60MM,10629110,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21751.00,6525.30,8439.39,18488.35,,10657.99,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,9135.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,8439.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9244.17,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16313.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10875.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18488.35,,,percent of total billed charges,,,9787.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CONE ARCOS REV SZB 60MM,10629110,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21751.00,6525.30,9135.42,18488.35,,10657.99,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,9135.42,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,10971.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9244.17,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,16313.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,10875.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16313.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,18488.35,,,percent of total billed charges,,,10005.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER ACETAB HW G7 36MM SZ G,10629111,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3934.00,1180.20,1526.39,3343.90,,,,,,,,,,,,,,,,,,,,1526.39,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3343.90,,,percent of total billed charges,,,1770.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER ACETAB HW G7 36MM SZ G,10629111,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3934.00,1180.20,1671.95,3343.90,,,,,,,,,,,,,service not payable,,,,,,,1984.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1671.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2950.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1967.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2950.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3343.90,,,percent of total billed charges,,,1809.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL ACETAB G7 4H 58MM SZG,10629112,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL ACETAB G7 4H 58MM SZG,10629112,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM 36MM 0 12/14,10629113,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM 36MM 0 12/14,10629113,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SFC PSN L 12MM 4-5/CD,10629114,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SFC PSN L 12MM 4-5/CD,10629114,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP STEM FEM PSN SZ4 LT,10629115,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP STEM FEM PSN SZ4 LT,10629115,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP STEM FEM PSN SZ10 LT,10629116,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP STEM FEM PSN SZ10 LT,10629116,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURF LT 6-9EF 12MM,10629117,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURF LT 6-9EF 12MM,10629117,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM KNEE PSN RT SZ9,10629118,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM KNEE PSN RT SZ9,10629118,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURF PSN R 10MM 6-9,10629119,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURF PSN R 10MM 6-9,10629119,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP STEM FEM PSN SZ12 LT,10629120,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP STEM FEM PSN SZ12 LT,10629120,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE G7 LPR DOME 6.5X50,10629121,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,716.00,214.80,277.81,608.60,,,,,,,,,,,,,,,,,,,,277.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,322.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE G7 LPR DOME 6.5X50,10629121,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,716.00,214.80,304.30,608.60,,,,,,,,,,,,,service not payable,,,,,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,537.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE G7 LPR DOME 6.5X60,10629122,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,716.00,214.80,277.81,608.60,,,,,,,,,,,,,,,,,,,,277.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,322.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE G7 LPR DOME 6.5X60,10629122,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,716.00,214.80,304.30,608.60,,,,,,,,,,,,,service not payable,,,,,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,537.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURFACE PSN 11MM LT,10629123,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURFACE PSN 11MM LT,10629123,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW BONE G7 LPR DOME 6.5X70,10629124,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,716.00,214.80,277.81,608.60,,,,,,,,,,,,,,,,,,,,277.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.60,,,percent of total billed charges,,,322.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW BONE G7 LPR DOME 6.5X70,10629124,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,716.00,214.80,304.30,608.60,,,,,,,,,,,,,service not payable,,,,,,,361.15,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,304.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,537.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,358.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,537.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,608.60,,,percent of total billed charges,,,329.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BUR STRAIGHT 8MM DIA2MM,10629125,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,219.00,65.70,84.97,186.15,,,,,,,,,,,,,,,,,,,,84.97,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.15,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUR STRAIGHT 8MM DIA2MM,10629125,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,219.00,65.70,93.08,186.15,,,,,,,,,,,,,service not payable,,,,,,,110.46,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,93.08,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,164.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,109.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,164.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,186.15,,,percent of total billed charges,,,100.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR 40MM 12MM,10629126,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR 40MM 12MM,10629126,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR 40MM 9MM,10629127,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR 40MM 9MM,10629127,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR 40MM  6MM,10629128,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR 40MM  6MM,10629128,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR 40MM  3MM,10629129,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR 40MM  3MM,10629129,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR STD 40MM,10629130,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR STD 40MM,10629130,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR 40MM - 3MM,10629131,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR 40MM - 3MM,10629131,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM HIP COCR 40MM - 6MM,10629132,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM HIP COCR 40MM - 6MM,10629132,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 38MM -4,10629133,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 38MM -4,10629133,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHEATH INTRO DRYSEAL 20FRX33CM,10629134,CDM,0272,RC,C1894,HCPCS,,,,,,outpatient,facility,,,2601.00,780.30,1105.42,2210.85,,1607.42,,,percent of total billed charges,,,,,,,,service not payable,1269.29,,,percent of total billed charges,,,1311.94,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1105.42,,,percent of total billed charges,,,,,,,,,1950.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1300.5,,,percent of total billed charges,,,,,,,,service not payable,1950.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2210.85,,,percent of total billed charges,,,1196.46,,,percent of total billed charges,,,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,1690.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 38MM 0,10629135,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 38MM 0,10629135,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 38MM 4,10629136,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 38MM 4,10629136,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 38MM 8,10629137,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 38MM 8,10629137,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 44MM 8,10629138,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 44MM 8,10629138,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 44MM -8,10629139,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 44MM -8,10629139,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
HEAD FEM COCR 12/14 44MM -4,10629140,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2460.00,738.00,954.48,2091.0,,,,,,,,,,,,,,,,,,,,954.48,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.0,,,percent of total billed charges,,,1107.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEAD FEM COCR 12/14 44MM -4,10629140,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2460.00,738.00,1045.5,2091.0,,,,,,,,,,,,,service not payable,,,,,,,1240.82,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1045.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1845.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1230.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1845.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2091.0,,,percent of total billed charges,,,1131.60,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 42MM A,10629141,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 42MM A,10629141,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 44MM A,10629142,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 44MM A,10629142,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 46MM B,10629143,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 46MM B,10629143,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 48MM C,10629144,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 48MM C,10629144,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 50MM D,10629145,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 50MM D,10629145,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 54MM F,10629146,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 54MM F,10629146,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 56MM F,10629147,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 56MM F,10629147,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 58MM G,10629148,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 58MM G,10629148,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURF 14MM RT EF,10629149,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURF 14MM RT EF,10629149,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 60MM G,10629150,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 60MM G,10629150,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 62MM H,10629151,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 62MM H,10629151,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 64MM H,10629152,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 64MM H,10629152,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURF 16MM RT EF,10629153,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURF 16MM RT EF,10629153,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 66MM I,10629154,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 66MM I,10629154,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURF 18MM RT EF,10629155,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURF 18MM RT EF,10629155,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI G7 SZ 68MM I,10629156,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4426.00,1327.80,1717.29,3762.10,,,,,,,,,,,,,,,,,,,,1717.29,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3762.10,,,percent of total billed charges,,,1991.7,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI G7 SZ 68MM I,10629156,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4426.00,1327.80,1881.05,3762.10,,,,,,,,,,,,,service not payable,,,,,,,2232.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1881.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3319.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2213.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3319.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3762.10,,,percent of total billed charges,,,2035.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTICULAR SURF 20MM RT EF,10629157,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTICULAR SURF 20MM RT EF,10629157,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 42MM A,10629158,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 42MM A,10629158,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 10MM 10-11 EF,10629159,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 10MM 10-11 EF,10629159,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 12MM 10-11 EF,10629160,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 12MM 10-11 EF,10629160,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 44MM A,10629161,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 44MM A,10629161,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 14MM 10-11 EF,10629162,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 14MM 10-11 EF,10629162,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 46MM B,10629163,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 46MM B,10629163,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 16MM 10-11 EF,10629164,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 16MM 10-11 EF,10629164,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 48MM C,10629165,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 48MM C,10629165,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 56MM F,10629166,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 56MM F,10629166,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 10MM 6-9 GH,10629167,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 10MM 6-9 GH,10629167,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 62MM H,10629168,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 62MM H,10629168,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 66MM I,10629169,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 66MM I,10629169,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 12MM 6-9 GH,10629170,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 12MM 6-9 GH,10629170,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 68MM I,10629171,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 68MM I,10629171,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 70MM I,10629172,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 70MM I,10629172,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 72MM I,10629173,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 72MM I,10629173,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 74MM J,10629174,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 74MM J,10629174,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 76MM J,10629175,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 76MM J,10629175,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 14MM 6-9 GH,10629176,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 14MM 6-9 GH,10629176,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 78MM J,10629177,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 78MM J,10629177,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL OSSEOTI MULTI G7 80MM J,10629178,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11425.00,3427.50,4432.90,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4432.90,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9711.25,,,percent of total billed charges,,,5141.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL OSSEOTI MULTI G7 80MM J,10629178,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11425.00,3427.50,4798.5,9711.25,,5598.25,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4798.5,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5762.77,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4855.62,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8568.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5712.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8568.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9711.25,,,percent of total billed charges,,,5255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 16MM 6-9 GH,10629179,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 16MM 6-9 GH,10629179,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 18MM 6-9 GH,10629180,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 18MM 6-9 GH,10629180,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 20MM 6-9 GH,10629181,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 20MM 6-9 GH,10629181,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB CR X3 SZ4 10MM,10629182,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB CR X3 SZ4 10MM,10629182,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PROSTHESIS DISC CERV 13X17MM,10629183,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,18031.00,5409.30,6996.03,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,6996.03,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15326.35,,,percent of total billed charges,,,8113.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROSTHESIS DISC CERV 13X17MM,10629183,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,18031.00,5409.30,7573.02,15326.35,,8835.19,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,7573.02,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,9094.84,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,7663.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,13523.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,9015.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,13523.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,15326.35,,,percent of total billed charges,,,8294.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 10MM 10-12 GH,10629922,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 10MM 10-12 GH,10629922,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT10-12 12MM,10629923,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT10-12 12MM,10629923,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 14MM 10-12 GH,10629924,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 14MM 10-12 GH,10629924,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 16MM 10-12 GH,10629925,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 16MM 10-12 GH,10629925,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 10MM 10-12 J,10629926,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 10MM 10-12 J,10629926,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 12MM 10-12 J,10629927,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 12MM 10-12 J,10629927,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 14MM 10-12 J,10629928,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 14MM 10-12 J,10629928,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
INSERT TIB PSN R 16MM 10-12 J,10629929,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSERT TIB PSN R 16MM 10-12 J,10629929,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ANCHOR SWIVELK TTP 4.75X19.1MM,10629930,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2318.00,695.40,899.38,1970.3,,,,,,,,,,,,,,,,,,,,899.38,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,985.15,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1159.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.3,,,percent of total billed charges,,,1043.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANCHOR SWIVELK TTP 4.75X19.1MM,10629930,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2318.00,695.40,985.15,1970.3,,,,,,,,,,,,,service not payable,,,,,,,1169.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,985.15,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1738.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1159.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1738.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1970.3,,,percent of total billed charges,,,1066.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
LINER G7 LONGEVITY 36MM SZD,10629931,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2623.00,786.90,1017.72,2229.55,,,,,,,,,,,,,,,,,,,,1017.72,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2229.55,,,percent of total billed charges,,,1180.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINER G7 LONGEVITY 36MM SZD,10629931,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2623.00,786.90,1114.77,2229.55,,,,,,,,,,,,,service not payable,,,,,,,1323.04,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1114.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1967.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1967.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2229.55,,,percent of total billed charges,,,1206.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 3H 42MM A,10629934,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 3H 42MM A,10629934,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 3H 44MM A,10629935,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 3H 44MM A,10629935,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 3H 46MM B,10629936,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 3H 46MM B,10629936,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 3H 48MM C,10629937,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 3H 48MM C,10629937,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 3H 50MM D,10629938,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 3H 50MM D,10629938,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 3H 52MM E,10629939,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 3H 52MM E,10629939,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 4H 54MM F,10629940,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 4H 54MM F,10629940,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 4H 62MM H,10629941,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 4H 62MM H,10629941,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 4H 64MM H,10629942,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 4H 64MM H,10629942,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 4H 66MM I,10629943,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 4H 66MM I,10629943,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SHELL FINNED G7 4H 68MM I,10629944,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3716.00,1114.80,1441.81,3158.60,,,,,,,,,,,,,,,,,,,,1441.81,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.60,,,percent of total billed charges,,,1672.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SHELL FINNED G7 4H 68MM I,10629944,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3716.00,1114.80,1579.3,3158.60,,,,,,,,,,,,,service not payable,,,,,,,1874.35,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1579.3,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2787.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1858.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2787.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3158.60,,,percent of total billed charges,,,1709.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
Rectal Anal Cytology (2000623),10630524,CDM,0311,RC,88112,CPT,,,,,,outpatient,facility,,,132.00,39.60,50.08,130.93,,102.3,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,other,,Procedure Lookup:  Procedure Code Tables:   [[AETNA LAB PROC]] 312.26% of Table Per Unit  Multipliers: 100%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  Not To Exceed:  100.00% of Charges in Service Type End Not To Exceed ,,,,,,,76.33,,,fee schedule,,,130.93,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,Procedure Lookup:  Procedure Code Tables:   [[CMS CLINICAL LABS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]   [[CMS ALL NE MPFS PROCS]] 215.00% of Table Per Unit with Revenue Code Table: [[LAB]]  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.95,,,fee schedule,,,,,,,,,99.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.10,,,fee schedule,,,,,,,,,99.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.2,,,percent of total billed charges,,,60.72,,,percent of total billed charges,,,,,,,,,56.79,,,fee schedule,,,,,,,,,,,,,,,50.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,
Rectal Anal Cytology (2000623),10630524,CDM,0311,RC,88112,CPT,05671,APC,,,,outpatient,facility,,,132.00,39.60,49.15,117.68,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,107.78,,,fee schedule,,,49.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [IOWA MCD NON-COVERED PROCS]: ($0.00)    [IOWA MCD ADD B RR PROCS]: ($0.00)    [IOWA MCD ADD B MP PROCS]: ($0.00)    [IOWA MCD ADD B MF NO MAX UNIT PROCS]: ($0.00)    [IOWA MCD ADD B MF MAX UNIT RATE PROCS]: ($0.00)    [IOWA MCD ADD B BC PROCS]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD ADD B APC MAX UNIT PROCS]: (100% of base rate in table)    [IOWA MCD ADD B APC MAX UNIT RATE PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with lowest reimbursement in the fee schedules listed below):    [IOWA MCD/CMS SI C E1 E2 F H M L Y PROCS]: (100% of base rate in table)    [IOWA MCD/CMS SI C E1 E2 F H M L Y MAX UNIT PROCS]: (100% of base rate in table)     No Mod 50    Apply the following multipliers to the calculated amount from above for ",52.26,,,fee schedule,,,117.68,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,106.22,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,49.15,,,fee schedule,,,52.26,,,fee schedule,,,,,,,,,51.24,,,fee schedule,,,,,,,,,49.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [IOWA MCD NON-COVERED PROCS]: $0.00   [IOWA MCD ADD B RR PROCS]: $0.00   [IOWA MCD ADD B MP PROCS]: $0.00   [IOWA MCD ADD B BC PROCS]: $0.00   [IOWA MCD ADD B MF PROCS]: $0.00   [IOWA MCD ADD B FS PROCS]: $0.00   [IOWA MCD ADD B APC-PR PROCS]: $0.00   [IOWA MCD ADD B APC-FS PROCS]: $0.00   [IOWA AMBULANCE HCPCS]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 160047     Replace blank service dates with Service To date     Zero denied totals     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Ignore Off Campus Pricing Logic     Alternate APC table: [IOWA APC RATE - MJE]     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Factor Overrides Applied:   Acute Wage Index Override: 1.00  Group (Not to Exceed):    100.00 % of Charges In Service Type If ( Current Amount = 0.00 )   Then:  Formula:= ( Addendum B APC-FS Reimb   ) ",52.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.24,,,fee schedule,,,,,,,,,,,,,,,51.24,,,fee schedule,,,,,,,,,51.75,,,fee schedule,,,,,,,,
Rectal Anal Cytology (2000623),10630524,CDM,0311,RC,88112,CPT,391,EAPG,,,,outpatient,facility,,,132.00,39.60,38.68,377.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N ",,,,,,,320.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [BCBS OP UNCLASSIFIED DRUGS PROC]: ($0.00)    [BCBS NO ASP RATE PROC]: ($0.00)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  NE BCBS EAPG   Override Provider Number: 1457448755   Percent Reimbursement: 100.00%   Cap line items at lesser of billed charges or payor reimbursement: N Formula:= ( Current Amount * 0.85 ) ",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.68,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.68,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,38.68,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,other,,Medicaid:  State: NE  Provider Number: '1457448755'  Percent Reimbursement: 100.00%  Product: EAPG  Lesser Of Comparison: N  Price To Zero On Error: N,,,,,,,,,,,,,59.52,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755HMO  Percent Reimbursement: 100% ,,,,,,,65.47,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% ,other,,Wellmark EAPG  Override Provider Number: 1457448755PPO  Percent Reimbursement: 100% 
SYSTEM SPINAL VISTA-S 5X11X14M,10630993,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2405.00,721.50,933.14,2044.25,,,,,,,,,,,,,,,,,,,,933.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2044.25,,,percent of total billed charges,,,1082.25,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SYSTEM SPINAL VISTA-S 5X11X14M,10630993,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2405.00,721.50,1022.12,2044.25,,,,,,,,,,,,,service not payable,,,,,,,1213.08,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1022.12,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1803.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1202.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1803.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2044.25,,,percent of total billed charges,,,1106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT THORACIC PROX 30X109MM,10630995,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,38126.00,11437.80,14792.89,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,14792.89,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32407.10,,,percent of total billed charges,,,17156.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT THORACIC PROX 30X109MM,10630995,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,38126.00,11437.80,16012.92,32407.10,,18681.74,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16012.92,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,19230.75,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,16203.55,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,28594.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,19063.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,28594.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,32407.10,,,percent of total billed charges,,,17537.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GRAFT DISSECTION ST 30X82MM,10630996,CDM,0278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,40023.00,12006.90,15528.92,34019.55,,19611.27,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,16809.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,15528.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17009.77,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,30017.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20011.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34019.55,,,percent of total billed charges,,,18010.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GRAFT DISSECTION ST 30X82MM,10630996,CDM,0278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,40023.00,12006.90,16809.66,34019.55,,19611.27,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,16809.66,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,20187.60,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,17009.77,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,30017.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,20011.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,30017.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,34019.55,,,percent of total billed charges,,,18410.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BRG TIB SSK PSC18X63/67MM,10630997,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,7164.00,2149.20,2779.63,6089.40,,3510.36,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3008.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2779.63,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3044.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,5373.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3582.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6089.40,,,percent of total billed charges,,,3223.80,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRG TIB SSK PSC18X63/67MM,10630997,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,7164.00,2149.20,3008.88,6089.40,,3510.36,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3008.88,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3613.52,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3044.70,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,5373.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3582.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,5373.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6089.40,,,percent of total billed charges,,,3295.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK TIB VANG 10X67MM,10630998,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4218.00,1265.40,1636.58,3585.30,,,,,,,,,,,,,,,,,,,,1636.58,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1792.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3163.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2109.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3585.30,,,percent of total billed charges,,,1898.10,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK TIB VANG 10X67MM,10630998,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4218.00,1265.40,1792.65,3585.30,,,,,,,,,,,,,service not payable,,,,,,,2127.56,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1792.65,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3163.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2109.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3163.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3585.30,,,percent of total billed charges,,,1940.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM STEM RT 60IN RT,10630999,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,24472.00,7341.60,9495.14,20801.20,,11991.28,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,10278.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,9495.14,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10400.6,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,18354.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12236.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20801.20,,,percent of total billed charges,,,11012.4,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM STEM RT 60IN RT,10630999,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,24472.00,7341.60,10278.24,20801.20,,11991.28,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,10278.24,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,12343.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,10400.6,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,18354.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,12236.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,18354.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,20801.20,,,percent of total billed charges,,,11257.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK AUGMENT FEM RM/LL 5X60MM,10631000,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK AUGMENT FEM RM/LL 5X60MM,10631000,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
BLOCK AUGMENT FEM LM/RL 5X60MM,10631001,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3688.00,1106.40,1430.94,3134.80,,,,,,,,,,,,,,,,,,,,1430.94,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3134.80,,,percent of total billed charges,,,1659.60,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLOCK AUGMENT FEM LM/RL 5X60MM,10631001,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3688.00,1106.40,1567.40,3134.80,,,,,,,,,,,,,service not payable,,,,,,,1860.23,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1567.40,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2766.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1844.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2766.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3134.80,,,percent of total billed charges,,,1696.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEM BCS JRNY II RT SZ 3,10631002,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,8196.00,2458.80,3180.05,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,3180.05,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6966.60,,,percent of total billed charges,,,3688.20,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEM BCS JRNY II RT SZ 3,10631002,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,8196.00,2458.80,3442.32,6966.60,,4016.04,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.32,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,4134.06,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,3483.30,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,6147.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,4098.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,6147.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,6966.60,,,percent of total billed charges,,,3770.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE LCP 6H 3.5X194MM RT,10631003,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6583.00,1974.90,2554.20,5595.55,,3225.67,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2764.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2554.20,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2797.78,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4937.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3291.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5595.55,,,percent of total billed charges,,,2962.35,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE LCP 6H 3.5X194MM RT,10631003,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6583.00,1974.90,2764.86,5595.55,,3225.67,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2764.86,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,3320.47,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2797.78,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4937.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,3291.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4937.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,5595.55,,,percent of total billed charges,,,3028.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
PLATE 1ST MTP FUSION LT,10631004,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2911.00,873.30,1129.47,2474.35,,,,,,,,,,,,,,,,,,,,1129.47,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1237.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2183.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1455.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2474.35,,,percent of total billed charges,,,1309.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PLATE 1ST MTP FUSION LT,10631004,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2911.00,873.30,1237.18,2474.35,,,,,,,,,,,,,service not payable,,,,,,,1468.31,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1237.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2183.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1455.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2183.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2474.35,,,percent of total billed charges,,,1339.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM FEM TPRLC 14X148MM,10631005,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,5574.00,1672.20,2162.71,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,2162.71,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.90,,,percent of total billed charges,,,2508.30,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM FEM TPRLC 14X148MM,10631005,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,5574.00,1672.20,2341.08,4737.90,,2731.26,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2341.08,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,2811.53,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,2368.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,4180.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2787.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4180.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,4737.90,,,percent of total billed charges,,,2564.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP FEMUR PSN NRW RT SZ11,10631006,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP FEMUR PSN NRW RT SZ11,10631006,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURF R 11MM 10-12GH,10631007,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURF R 11MM 10-12GH,10631007,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ARTIC SURF R 13MM 10-12GH,10631008,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2186.00,655.80,848.17,1858.10,,,,,,,,,,,,,,,,,,,,848.17,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1858.10,,,percent of total billed charges,,,983.70,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ARTIC SURF R 13MM 10-12GH,10631008,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2186.00,655.80,929.05,1858.10,,,,,,,,,,,,,service not payable,,,,,,,1102.62,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,929.05,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1639.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1093.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1639.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1858.10,,,percent of total billed charges,,,1005.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
SCREW LVL 1 THORACIC 2.3X9MM,10631009,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,951.00,285.30,368.99,808.35,,,,,,,,,,,,,,,,,,,,368.99,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.18,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,713.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,475.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.35,,,percent of total billed charges,,,427.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCREW LVL 1 THORACIC 2.3X9MM,10631009,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,951.00,285.30,404.18,808.35,,,,,,,,,,,,,service not payable,,,,,,,479.68,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,404.18,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,713.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,475.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,713.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,808.35,,,percent of total billed charges,,,437.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
STEM EPIPHYSIS HUM SZ1 D10 LG,10631010,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,11461.00,3438.30,4446.87,9741.85,,5615.89,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,4813.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to inpatient services,4446.87,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4870.93,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,8595.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5730.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9741.85,,,percent of total billed charges,,,5157.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
STEM EPIPHYSIS HUM SZ1 D10 LG,10631010,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,11461.00,3438.30,4813.62,9741.85,,5615.89,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,4813.62,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type,other,,Interim Value: Implant 278 Greater than 5000 Charges  100% of Charges in Service Type 42% of Charges in Service Type Paid in addition to outpatient services,5780.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,4870.93,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,8595.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,5730.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,8595.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,9741.85,,,percent of total billed charges,,,5272.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
GLENOSPHERE LAT 42MM 8,10631011,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4590.00,1377.00,1780.92,3901.5,,,,,,,,,,,,,,,,,,,,1780.92,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3901.5,,,percent of total billed charges,,,2065.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLENOSPHERE LAT 42MM 8,10631011,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4590.00,1377.00,1950.75,3901.5,,,,,,,,,,,,,service not payable,,,,,,,2315.20,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1950.75,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3442.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2295.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3442.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3901.5,,,percent of total billed charges,,,2111.40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SUR LT 8-11 EF 10MM,10631012,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SUR LT 8-11 EF 10MM,10631012,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
NAIL AFIXS PRX HUM R 9X160MM,10631013,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4544.00,1363.20,1763.07,3862.40,,,,,,,,,,,,,,,,,,,,1763.07,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.40,,,percent of total billed charges,,,2044.8,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAIL AFIXS PRX HUM R 9X160MM,10631013,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4544.00,1363.20,1931.2,3862.40,,,,,,,,,,,,,service not payable,,,,,,,2291.99,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1931.2,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3408.0,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2272.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3408.0,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3862.40,,,percent of total billed charges,,,2090.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
ADAPTER TRAY TIB OFFSET 2.5MM,10631014,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3454.00,1036.20,1340.15,2935.90,,,,,,,,,,,,,,,,,,,,1340.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1467.95,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2590.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1727.0,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2935.90,,,percent of total billed charges,,,1554.3,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADAPTER TRAY TIB OFFSET 2.5MM,10631014,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3454.00,1036.20,1467.95,2935.90,,,,,,,,,,,,,service not payable,,,,,,,1742.2,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1467.95,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2590.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1727.0,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2590.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2935.90,,,percent of total billed charges,,,1588.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
DEVICE FIX HAMMERTOE 10DEG SM,10631015,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4521.00,1356.30,1754.15,3842.85,,,,,,,,,,,,,,,,,,,,1754.15,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1921.42,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,3390.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2260.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3842.85,,,percent of total billed charges,,,2034.45,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE FIX HAMMERTOE 10DEG SM,10631015,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4521.00,1356.30,1921.42,3842.85,,,,,,,,,,,,,service not payable,,,,,,,2280.39,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1921.42,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,3390.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,2260.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,3390.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,3842.85,,,percent of total billed charges,,,2079.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPR FT SCREW MICRO 2.5X40MM,10631016,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPR FT SCREW MICRO 2.5X40MM,10631016,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMPR FT SCREW MINI 3.5X50MM,10631017,CDM,0278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1913.00,573.90,742.24,1626.05,,,,,,,,,,,,,,,,,,,,742.24,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.05,,,percent of total billed charges,,,860.85,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMPR FT SCREW MINI 3.5X50MM,10631017,CDM,0278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1913.00,573.90,813.02,1626.05,,,,,,,,,,,,,service not payable,,,,,,,964.92,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,813.02,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,1434.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,956.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,1434.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,1626.05,,,percent of total billed charges,,,879.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 13MM CD,10631018,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 13MM CD,10631018,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 14MM CD,10631019,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 14MM CD,10631019,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 16MM CD,10631020,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 16MM CD,10631020,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 18MM CD,10631021,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 18MM CD,10631021,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 20MM CD,10631022,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 20MM CD,10631022,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 10MM EF,10631023,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 10MM EF,10631023,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 11MM EF,10631024,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 11MM EF,10631024,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 12MM EF,10631025,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 12MM EF,10631025,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 13MM EF,10631026,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 13MM EF,10631026,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 14MM EF,10631027,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 14MM EF,10631027,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 16MM EF,10631028,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 16MM EF,10631028,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 18MM EF,10631029,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 18MM EF,10631029,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 20MM EF,10631030,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 20MM EF,10631030,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 10MM EF,10631031,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 10MM EF,10631031,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 11MM EF,10631032,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 11MM EF,10631032,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 12MM EF,10631033,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 12MM EF,10631033,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 13MM EF,10631034,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 13MM EF,10631034,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 14MM EF,10631035,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 14MM EF,10631035,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 16MM EF,10631036,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 16MM EF,10631036,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 18MM EF,10631037,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 18MM EF,10631037,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 20MM EF,10631038,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 20MM EF,10631038,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 10MM EF,10631039,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 10MM EF,10631039,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 11MM EF,10631040,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 11MM EF,10631040,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 12MM EF,10631041,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 12MM EF,10631041,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 13MM EF,10631042,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 13MM EF,10631042,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 14MM EF,10631043,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 14MM EF,10631043,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 16MM EF,10631044,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 16MM EF,10631044,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 18MM EF,10631045,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 18MM EF,10631045,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-11 20MM EF,10631046,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-11 20MM EF,10631046,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 10MM GH,10631047,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 10MM GH,10631047,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 11MM GH,10631048,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 11MM GH,10631048,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 12MM GH,10631049,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 12MM GH,10631049,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 13MM GH,10631050,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 13MM GH,10631050,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 14MM GH,10631051,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 14MM GH,10631051,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 16MM GH,10631052,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 16MM GH,10631052,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 18MM GH,10631053,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 18MM GH,10631053,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 6-9 20MM GH,10631054,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 6-9 20MM GH,10631054,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 10MM GH,10631055,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 10MM GH,10631055,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 11MM GH,10631056,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 11MM GH,10631056,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 12MM GH,10631057,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 12MM GH,10631057,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 13MM GH,10631058,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 13MM GH,10631058,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 14MM GH,10631059,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 14MM GH,10631059,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 16MM GH,10631060,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 16MM GH,10631060,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 18MM GH,10631061,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 18MM GH,10631061,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 20MM GH,10631062,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 20MM GH,10631062,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 10MM J,10631063,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 10MM J,10631063,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 11MM J,10631064,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 11MM J,10631064,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 12MM J,10631065,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 12MM J,10631065,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 13MM J,10631066,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 13MM J,10631066,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 16MM J,10631067,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 16MM J,10631067,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 18MM J,10631068,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 18MM J,10631068,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 10-12 20MM J,10631069,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3497.00,1049.10,1356.84,2972.45,,,,,,,,,,,,,,,,,,,,1356.84,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2972.45,,,percent of total billed charges,,,1573.65,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 10-12 20MM J,10631069,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3497.00,1049.10,1486.22,2972.45,,,,,,,,,,,,,service not payable,,,,,,,1763.89,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1486.22,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2622.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1748.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2622.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2972.45,,,percent of total billed charges,,,1608.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 12MM CD,10631070,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 12MM CD,10631070,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 14MM CD,10631071,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.15,,,percent of total billed charges,,,1475.55,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COMP ART SURF RT 3-5 14MM CD,10631071,CDM,0278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,3279.00,983.70,1393.58,2787.15,,,,,,,,,,,,,service not payable,,,,,,,1653.93,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 52.00% End FormulaCPE  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,,2459.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,,,,,,,,1639.5,,,percent of total billed charges,,Paid in addition to outpatient services ,,,,,,service not payable,2459.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,2787.15,,,percent of total billed charges,,,1508.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,
COMP ART SURF RT 3-5 16MM CD,10631072,CDM,0278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,3279.00,983.70,1272.25,2787.15,,,,,,,,,,,,,,,,,,,,1272.25,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE ,other,,40.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 97.00% End FormulaCPE  Paid in addition to inpatient services,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.58,,,percent of total billed charges,,Paid in addition to inpatient services ,,,,,,,24